Inspection on 18/05/06 for Abbotts Lodge

This inspection was carried out on 18th May 2006.

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

Other inspections for this house

Abbotts Lodge 17/05/07

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 18th May 2006 9:30am Abbotts Lodge DS0000007166.V293145.R01.S.doc Version 5.1 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.V293145.R01.S.doc Version 5.1 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.V293145.R01.S.doc Version 5.1 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.V293145.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th November 2005 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.V293145.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted over five hours, and involved discussion with the registered provider/manager, Mr Hoozeer, staff on duty and four of the home’s six service users. The inspector case-tracked one new admission, and examined policies, procedures, service user, staff records and other documentation relating to the management and running of the home. As a result of this inspection, there are 12 requirements and 1 recommendation. Of the 12 requirements, there are 3 requirements that have not been met from the previous inspection. The inspector was generally impressed with the standard of care and support provided to service users, and with the commitment shown by the home’s provider/manager and staff in creating an enabling and inclusive home environment. This is a small group home, which was observed to provide a very homely atmosphere, and an environment in which service users are encouraged to develop their abilities and independent living skills. There are, however, training needs, specific to this client group, which must be addressed if the care and support needs of the Home’s service users are to be fully met. What the service does well: Prospective service users 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 service users are being provided with the opportunity to visit the home, and stay overnight, before deciding whether the home is likely to meet their needs. Generally, service users admitted to the home have been fully assessed and know that their individual needs will be met. Service users 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. Service users are enabled to participate fully in decisions that affect them and their day-to-day lives in the home. Abbotts Lodge DS0000007166.V293145.R01.S.doc Version 5.1 Page 6 Service users are encouraged and supported to develop an independent lifestyle, with risk assessments being carried out for activities that involve responsible risk-taking. Service users are being assessed regarding potential risks to their health and safety, and are enabled to take responsible risks wherever possible. Service users are provided with a range of opportunities for recreational and social activities, which are in accord with their social, cultural and religious needs. Service users are enabled to participate fully, and to exercise choice and control in their daily routines and activities. Service users are encouraged to maintain contact with their family and friends, and to maintain links with the local community. Service users’ rights and responsibilities are being respected and recognised in their day-to-day lives. Service users are being enabled to be as independent as possible within the constraints associated with their disabilities. There is choice and flexibility with meal arrangements. The quality of food is wholesome, nutritious and varied, with meals being taken in a pleasant and congenial setting. The health, personal and social care needs of service users are being fully met, and their privacy respected. Service users’ health and emotional needs are being well met. Service users are being protected by the home’s medication policy and procedures, and by the provision of accredited medication training for all care staff. Service users live in a safe, hygienic and well-maintained environment with access to appropriate and sufficient communal facilities. Service users’ rooms are safe, comfortable and pleasantly decorated, being suited to their individual needs. Service users are being supported by an effective staff team. Service users are being protected by the home’s recruitment policy and procedures. Generally, service users can be assured that their needs are being safeguarded, through staff being appropriately supported, and supervised on a regular basis. However, an appropriate system of appraising staff must be developed. Abbotts Lodge DS0000007166.V293145.R01.S.doc Version 5.1 Page 7 Service users 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 rights and best interests of service users are being safeguarded by the home’s record keeping policies and procedures. Generally, the health, safety and welfare of staff are being appropriately protected. Updated infection control training is, however, required. What has improved since the last inspection? What they could do better: The home has found it difficult to fully meet the needs of one recently admitted service user, with dementia, who has presented more complex needs. The home must demonstrate that the range of needs presented by service users are being fully met. Training relating to the needs of younger adults with learning disabilities, and with challenging behaviour, must be provided for all staff. Abbotts Lodge DS0000007166.V293145.R01.S.doc Version 5.1 Page 8 While issues relating to bereavement and loss are being handled with respect, relevant training designed to raise awareness of these issues needs to be extended to all staff. Generally, service users are having their needs well met by an appropriately trained and qualified staff group. There are, however, some high priority training needs, for work with this service user group, which remain to be met. For service users to feel assured that staff development is being properly monitored and progressed, staff induction and training checklists must be developed and maintained. The home needs to demonstrate, through the development of its quality assurance processes, that it is obtaining widespread feedback regarding the extent to which the home is supporting service users and meeting its aims and objectives. 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. Abbotts Lodge DS0000007166.V293145.R01.S.doc Version 5.1 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.V293145.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 to 5 Prospective service users 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. The Service Users Guide has been revised in a new pictorial format making it more comprehensible for service users. Prospective service users are being provided with the opportunity to visit the home, and stay overnight, before deciding whether the home is likely to meet their needs. Generally, service users admitted to the home have been fully assessed and know that their individual needs will be met. However, the home has found it difficult to fully meet the needs of one recently admitted service user, with dementia, who has presented more complex needs. The home must demonstrate that the range of needs presented by service users are being fully met. Training relating to the needs of younger adults with learning disabilities, and with challenging behaviour, must be provided for all staff. Each service user is now being provided with a revised service user agreement, the format of which is more appropriate to the communication needs of service users living at the home. EVIDENCE: Abbotts Lodge DS0000007166.V293145.R01.S.doc Version 5.1 Page 11 Prospective service users are provided with the information they need to make an informed choice. The home has a Statement of Purpose (SOP) and a Service User Guide (SUG). These provide the information listed in the Regulations and National Minimum Standards, and have been reviewed on 20/12/05 and 13/1/06 respectively. All service users are given a copy of the Service User Guide. These, together with the home’s service user agreement, have been rewritten in a pictorial form so as to make these more comprehensible for service users. The registered provider/manager, Mr Hoozeer, advised the inspector that any potential service user is invited to visit the home and to meet service users 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 service user, nearest relative and 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 service user’s needs and is to become permanent. Each service user has a contract provided by the Local Authority. Each service user is also given the home’s own contract, which details conditions of residence and the services to be provided by the home. This has now been produced in a pictorial form so as to aid service users’ understanding of its contents. In addition to the assessments provided by care managers, the home completes its own detailed assessment (based on functional performance). The risk assessment format has been revised to provide a more 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. Since the last inspection, there has been one new admission to the home, for a service user with associated dementia, for which care management information had been provided and a variation to the home’s registration had been agreed. The home has completed its own assessments and care plan, and all relevant medical information obtained. An initial review attended by the care manager has taken place. Whilst initially presenting as settled, the placement has not, it seems, subsequently proved to be altogether appropriate in meeting the service user’s specific needs, and the manager advised that it has now been agreed with the care manager that another placement should be identified. Abbotts Lodge DS0000007166.V293145.R01.S.doc Version 5.1 Page 12 The inspector met the service user on her return from day care, but was unable to engage her verbally due to her severe communication difficulties. She did, however, present as responsive on an interactive level, and as being well accepted within the group. It was apparent, however, that she is more highly dependent than the other service users, and that her specific needs are complex and difficult to meet in this placement. The inspector was advised that there has been ongoing psychiatric contact that has tended to support this view. Notes on the service user’s file were examined. Whilst staff have all received dementia awareness training, it is clear that there have been ongoing behavioural problems that have proved difficult to manage. Whilst the needs of other service users are demonstrably being met, it is for this reason that the home has failed to meet Standard 3 on this inspection. Twelve-monthly care management reviews were evidenced to have taken place for all service users. These indicate that service users care and support needs are generally being well met in this home, and that there is a high level of satisfaction from family and friends. There was also evidence of a positive and enabling ethos amongst the staff group, which was evident from observation and discussion with two staff members on duty. The inspector spoke to three service users, all of whom presented as happy and settled, and involved in regular activities and in developing their independent living skills within and outside of the home. Staff were observed to be facilitative in their approach, and to be interacting in a positive and caring way with service users. The home was again evidenced to have a real ‘family’ atmosphere, with mutual encouragement and support being apparent between, and within, service users and staff. Generally, the needs of service users are being well met. There are, however, two requirements that remain to be met, for staff to undertake specific, updated training relating to work with service users who have learning difficulties, and for training in challenging behaviour. The inspector understands that there have been difficulties in accessing this training locally, but was able to advise on other training agencies that could provide this. The inspector stressed the need for these requirements to be met within the extended time-scale agreed. Abbotts Lodge DS0000007166.V293145.R01.S.doc Version 5.1 Page 13 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 to 9 Service users 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. Service users are enabled to participate fully in decisions that affect them and their day-to-day lives in the home. Service users are encouraged and supported to develop an independent lifestyle, with risk assessments being carried out for activities that involve responsible risk-taking. Service users are being assessed regarding potential risks to their health and safety, and are enabled to take responsible risks wherever possible. EVIDENCE: Abbotts Lodge DS0000007166.V293145.R01.S.doc Version 5.1 Page 14 Each service user who lives in the home has a community care plan review 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 the service user, his/her relative(s), representatives and any significant professionals including the care manager and day centre key worker. The inspector examined three service user files. Care plan review meetings were evidenced to be taking place on a six-monthly basis. Care plans should, however, be reviewed The home has introduced a new service user plan format that 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 service user has been given a copy of these. The inspector spoke to three service users regarding their participation in dayto-day routines and activities, and to staff on duty. This indicated that service users have a strong sense of identity with “their home” and derive satisfaction from their participation in day-to-day routines and activities. This includes activities at a local day centre, and within the local community. There was evidence from the service users, and from care plans and review notes, that service users are able to make choices in their day-to-day routines and activities, and are consulted regarding decisions that affect them. Service users 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 users 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. Staff members on duty were observed to work with service users in an enabling and client-centred way. 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 the welfare/interests of service users. There was evidence that service users are supported to take risks in developing independent skills and abilities. Service users are encouraged to access local recreational and shopping facilities, and to engage in a range of activities. The inspector examined a sample of risk assessments that have been completed for service users living at the home. Over the last year, a more generic approach to risk assessment has been developed. Risk assessment formats cover areas such as Mood, Risk-taking, Vulnerability, Aggression and Abbotts Lodge DS0000007166.V293145.R01.S.doc Version 5.1 Page 15 Verbal Abuse, together with General Risk, providing a more comprehensive assessment of each service user. These are being updated in line with annual review, and more frequently if the need arises. One service user is currently in hospital following a fall in her room. The inspector read the service user’s notes and discussed this with the provider/manager. He was satisfied that, on the basis of the information provided, this was an accident that had been difficult to anticipate or prevent. However, there is a need for the risk of falls to be re-assessed, and for a new risk assessment to be completed with the service user once she has been discharged from hospital; a requirement applies. Abbotts Lodge DS0000007166.V293145.R01.S.doc Version 5.1 Page 16 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11 to 17 Service users are provided with a range of opportunities for recreational and social activities, which are in accord with their social, cultural and religious needs. Service users are enabled to participate fully, and to exercise choice and control in their daily routines and activities. Service users are encouraged to maintain contact with their family and friends, and to maintain links with the local community. Service users’ rights and responsibilities are being respected and recognised in their day-to-day lives. Service users are being enabled to be as independent as possible within the constraints associated with their disabilities. There is choice and flexibility with meal arrangements. The quality of food is wholesome, nutritious and varied, with meals being taken in a pleasant and congenial setting. Abbotts Lodge DS0000007166.V293145.R01.S.doc Version 5.1 Page 17 EVIDENCE: The philosophy of the home, as indicated in the home’s Statement of Purpose, is to promote independence and enable service users to develop a wide range of social and independent living skills. The inspector spoke to three service users upon their return from the local day centre that they attend on weekdays. They indicated that they liked attending the day centre and that that they greatly enjoyed the social contact and activities offered there. Satisfaction was also expressed with the home and the opportunities offered for personal development and leisure activity. One service user enjoys gardening, having open employment in a garden centre, while another is interested in computers, and has been attending a computer course at a local college. A fourth service user, more recently admitted, was unable to communicate verbally, but gave some indication that that she likes going with the others to the day centre. Service users are evidenced in care plans to have opportunities for personal and social development. This includes attendance at the local day centre, where there is a varied programme of activities. Service users also attend classes provided by the Local Authority for adults with special needs. These include arts and crafts, pottery, cookery, self-advocacy, and developing independent living skills. Service users also have the opportunity to attend a mini-gym and participate in physical activities at a local leisure centre. Within the home service users are 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. Service users have opportunities 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. Service users also maintain regular contact with residents at a small sister home, and participate in joint events and outings from time to time. At Christmas, service users attended a pantomime, and a party was organised for service users from the two homes at a local hall. The home has its own transport that it uses for day trips and holidays. Abbotts Lodge DS0000007166.V293145.R01.S.doc Version 5.1 Page 18 There are occasional day trips out during the summer and there is a week’s holiday that has been booked at the end of May at a holiday centre in the Isle of Wight. Service users indicated how much they were looking forward to this. Last year (2005) service users went on a successful week’s holiday to a holiday centre in Hayling Island. Two service users also indicated that they were planning to go away on holidays with family later this year, one to Cornwall and the other to visit relatives in Canada. The home was evidenced to encourage service users to maintain family links and friendships both inside and outside of the home. Service users indicated that they 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. Whilst there was no direct feedback from relatives, previous feedback and review notes indicate that the home is positively regarded and that friends and family are consulted and encouraged to maintain their contact. Service users indicated to the inspector that they feel able to exercise a considerable degree of choice in their day-to-day lives, and that there are no unnecessary restrictions on their movements. The philosophy of the home is to enable service users to be as independent as possible within the constraints associated with their disabilities. Any restrictions, based on health and safety considerations, and risk assessed, are detailed in the Service User Plans. Service users again expressed their satisfaction with the food provided; if they wish, service users are able to assist in preparing sandwiches and light snacks, and to help with laying the table. Service users 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 twoweek period. These offer a balanced, nutritious and varied range of food. One service user 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.V293145.R01.S.doc Version 5.1 Page 19 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 to 21 The health, personal and social care needs of service users are being fully met, and their privacy respected. Service users’ health and emotional needs are being well met. Service users are being protected by the home’s medication policy and procedures, and by the provision of accredited medication training for all care staff. While issues relating to bereavement and loss are being handled with respect, relevant training designed to raise awareness of these issues needs to be extended to all staff. EVIDENCE: Abbotts Lodge DS0000007166.V293145.R01.S.doc Version 5.1 Page 20 The home has a friendly, homely feel with a small staff team, which works in shifts of two with the six service users. 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. The inspector spoke at length with three service users. Feedback indicated that both personal and social care needs are being well met, with good support from staff. And that the privacy and independence of service users is being respected. Information recorded in daily notes and service user plans indicated that service users’ needs are being well monitored and recorded. The healthcare needs of service users are being met in this home. The inspector examined a number of service users files. These evidenced that there is regular contact with health care professionals. This includes visits from the home’s GP, five of the service users being registered with this practice. One service user has retained his own GP in accordance with his wishes. There are also monthly visits from a Psychiatrist, and periodic contact from a chiropodist and a visiting optician. Annual dental checks are also arranged. There is monitoring of service users’ weight, with weight charts being maintained, and, where appropriate, service users are assisted to manage their weight through a “healthy eating” program. The home has appropriate medication policy and procedures in place. The home uses the Monitored Dosage System for administering medication. All but one new staff member (training having been arranged for 22/5/06) have undertaken accredited medication training. A separate record is now being maintained for all receipts and disposals of medication, has been met. The home received an annual pharmacy inspection on 10/11/05 as a result of which the home was required to keep a record of all homely remedies that are administered, and to put a date on the label of any creams that are used. The home’s medication policy does not currently include a section on homely remedies, hence this needs to be included; a requirement applies. 3 of the home’s 6 service users require medication, none of whom have been assessed as being able to self-administer. The home maintains MAR sheets for administering medication. These were checked and found to be in order. There is a requirement from the last inspection, for all staff to receive training in loss and bereavement, which remains to be met. Abbotts Lodge DS0000007166.V293145.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 The home has a complaints policy and procedure in place. This has been amended to ensure that the complaints procedure is open and accessible, and is not restricting in any way. Service users are protected from abuse and live in a safe environment. Statutory adult protection training has now been extended to all staff. EVIDENCE: Abbotts Lodge DS0000007166.V293145.R01.S.doc Version 5.1 Page 22 There have been no complaints since the last inspection on 31/11/05. The complaints procedures and information given to service users is up to date, and comprehensive, providing details as to how, and to whom they should complain. Service users 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. Following a requirement from the previous inspection, the complaints procedure has been amended so as to make clear that independent advocacy, and/or communication support, can be arranged if the service user requires this. No allegations of abuse have been recorded in the last 12 months, and no concerns were expressed by service users during the 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 familiarised with these policies. 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. In line with a previous requirement, all 6 staff members (including a recent new staff member) have now completed Sutton’s multi-agency Adult Protection training. Abbotts Lodge DS0000007166.V293145.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Service users live in a safe, hygienic and well-maintained environment with access to appropriate and sufficient communal facilities. Service users’ 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 service users. Service users presented as settled and comfortable in their surroundings, and the environment was observed to have a very ‘homely’ feel. Feedback from service users indicated that they are happy with their environment and that the facilities provided are meeting their needs. Abbotts Lodge DS0000007166.V293145.R01.S.doc Version 5.1 Page 24 Service users in this home are younger adults between 25 and 55 years of age and are reasonably mobile. This is a small home is an ordinary domestic dwelling that has been enlarged to provide care for up to six service users. The home is generally well maintained, and in a good decorative state, with service users having access to safe and comfortable facilities. The lounge and adjoining conservatory ‘dining area’ have had new light coloured wooden flooring laid down, replacing the previous lino and carpeting. The accommodation needs of the service users are being well met, with service users expressing their satisfaction with these. There are four single bedrooms, and one double bedroom, which the two service users have been happy to share. While there is no “compensatory” space for the two service users whose bedrooms are less than 10 square metres, these arrangements remain acceptable to the present service users. Service users’ rooms were observed to be safe, comfortable and pleasantly arranged, reflecting service users’ personal identities, and being suited to individuals’ needs. Each bedroom is decorated according to the service users’ choice and includes the required furniture and fittings. One bedroom has recently been re-carpeted. The home has two toilets for service users 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. No service users require specialist facilities at this time. The home has a small laundry that is adequate for the purpose. Service users assist in various ways with practical domestic tasks, helping to keep their rooms clean and tidy, and in helping to look after their home. Apart from emergency call systems, bath seats and rails, the current service users 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 service users can easily access from the conservatory. There is a small patio with garden furniture where service users can sit and enjoy the garden. One service user, assists with maintaining the garden, from which he derives considerable satisfaction. Abbotts Lodge DS0000007166.V293145.R01.S.doc Version 5.1 Page 25 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 to 36 Generally, service users are having their needs well met by an appropriately trained and qualified staff group. There are, however, some high priority training needs, for work with this service user group, which remain unmet. For service users to feel assured that staff development is being properly monitored and progressed, staff induction and training checklists must be maintained. Service users are being supported by an effective staff team. Service users are being protected by the home’s recruitment policy and procedures. Generally, service users can be assured that their needs are being safeguarded, through staff being appropriately supported, and supervised on a regular basis. However, an appropriate system of appraising staff must be developed and maintained. EVIDENCE: Staff are provided with detailed job descriptions that clarify their roles and responsibilities. Abbotts Lodge DS0000007166.V293145.R01.S.doc Version 5.1 Page 26 The home has an induction programme in place, which new staff members must complete over their first six weeks of working in the home. The inspector identified the need for an induction checklist to be kept on each staff file so as to evidence the progress made in completing the programme. This should identify the list of components in the induction (training, learning tasks, and familiarity with key policies/procedures etc) and, for each component, should include the date when this is completed, and the signature, of both the staff member, and the supervisory person. A requirement applies. Generally, staff are evidenced to have relevant qualifications, skills and experience with which to deliver the services and care which the home aims to provide. The inspector was informed that six of the eight care staff employed have obtained their NVQ Level 2, while one staff member has an NVQ Level 3 and is currently studying for her NVQ Level 4. This is a high level of staff possessing NVQ qualifications, for which the registered provider is to be commended. The figure well exceeds the 50 target set in Standard 32.6, representing approximately 86 of the staff group. The inspector spoke to two staff on duty, which indicated that they have been updating their training, and had found the recent training in dementia awareness to be particularly beneficial. One of the two, a recently recruited staff member, has been completing her induction programme, which she felt was meeting her needs. The two staff members also indicated that they are being well supported in their roles, and that supervision is being provided. All staff have now received statutory adult protection and medication training, with recent training having taken place in dementia awareness (9/5/06). There has also been training within the last 12 months in autism awareness (1/7/05), Epilepsy/First Aid (9/5/06), and food hygiene (5/7/05). Updated training is being planned for fire safety and health & safety. There are, however, unmet training needs which have been prioritised for work with this service user group, for which previous requirements apply. These relate to the need for staff to attend updated training specific to the needs of service users who have learning difficulties, and for training that relates to service users who present challenging behaviour. The manager/owner stated that staff have been on LB Sutton’s waiting list and that dates scheduled in February 2006 had been cancelled. And that the home has had difficulty accessing the relevant training. The inspector advised that these training needs are a high priority and that he must endeavour to access training through other training agencies (e.g. Mencap, NESCOT or Croydon College). Abbotts Lodge DS0000007166.V293145.R01.S.doc Version 5.1 Page 27 The inspector identified a need for a checklist of training undertaken by each staff member to be placed on his or her staff file. This must list all the staff training required, together with the date(s) when each training course has been completed. This should assist the monitoring of each staff member’s training needs, and help in identifying areas where training is required or needs updating. The home is evidenced to have the numbers and skill mix of staff on duty with which to meet service users’ needs. The duty rota was examined and evidenced to include two on at all times during the day on weekdays when service users are around- apart from 9am to 3 pm when service users attend the day centre. 2 staff are on 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. Interactions observed between staff and service users on this, and previous inspections, are generally very positive, with service users indicating that they feel well supported and enabled by staff to develop their daily living skills. 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 28/3/06). The staff file was inspected; this evidenced an up-to-date CRB check, and the completion of all necessary recruitment and identity checks. The inspector spoke to the new staff member who was on duty. She indicated that she was feeling well supported in her role and enjoyed working at the home. She has attended statutory adult protection training and has been completing her induction. Medication training is scheduled for 22/5/06. The inspector examined a sample of staff supervision files and evidenced that staff are now receiving regular two-monthly one-to-one supervision. The supervision format has been further revised so as to provide a fuller record of the issues raised and actions/decisions agreed. The supervision record must be signed and dated by both the supervisor and supervisee. In view of previous concerns, regarding the frequency of supervision, this will be rigorously monitored on future inspections. A requirement in respect of staff appraisal has been partly, but not fully met. Abbotts Lodge DS0000007166.V293145.R01.S.doc Version 5.1 Page 28 Whilst the registered provider/manager was evidenced to be holding appraisals with staff, these are failing to identify work and learning 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, should also be completed prior to the appraisal session taking place. A requirement applies. Abbotts Lodge DS0000007166.V293145.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 to 42 Service users 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 needs to demonstrate, through the development of its quality assurance processes, that it is obtaining widespread feedback regarding the extent to which the home is supporting service users 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. Generally, the health, safety and welfare of staff are being appropriately protected. Updated infection control training is, however, required. EVIDENCE: Abbotts Lodge DS0000007166.V293145.R01.S.doc Version 5.1 Page 30 The owner/manager, Mr Hoozeer, has had twelve 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. Generally, the inspection evidences, across the standards, that the home is being managed in a caring and competent manner. The atmosphere in this small group home is evidenced as being open, positive and inclusive. Discussion with three service users indicates that they like the home and that it is being managed in a way that meets their needs, and which involves them in decisions regarding their day-to-day living and routines. Staff to whom the inspector spoke indicated that they are provided with relevant training and are being appropriately supported. Service users present as settled and reassured by the supportive approach of the manager and staff, and no concerns were expressed. Following a requirement from the previous inspection, the home has piloted a questionnaire for service users. This takes the form of a short, written questionnaire but is not, however, suitable for service users who have significant communication difficulties. A more appropriate format (using Makaton) needs to be developed. The questionnaire for service users must also be developed so as to enable service users to give reasons for yes/no tick box answers. Questionnaires must also be developed so as to obtain the views of relatives, friends, professionals and others, regarding their views as to the services provided by the home and where improvements could be made. A requirement applies. A Development Plan has been put in place for 2004/05. This needs, however, to be linked in to the quality assurance processes that are being developed. Any future report should draw on the views expressed in surveys with service users, relatives/friends, professionals and other parties, and provide an indication of the extent to which the home’s aims and objectives are being met. Priorities and targets for the year ahead, to address any deficiencies or service developments required, should be identified. An audit must be completed and a Development Plan put in place for the 2005/06; a requirement applies. The rights and best interests of service users 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. Abbotts Lodge DS0000007166.V293145.R01.S.doc Version 5.1 Page 31 Generally, the health, safety and welfare of staff are being appropriately protected. Updated infection control training for staff is, however, required, for which a requirement applies. The inspector completed health and safety checks with updated certification having been provided for fire inspection (20/4/06), water/legionella (20/2/06), gas (31/3/06), electrical installation (11/11/05) and portable electrical appliances (9/11/05), and environmental health. Weekly fire alarm checks, and water temperature checks, monthly checks of emergency lighting and call systems and monthly fire drills were evidenced as having been carried out on a regular basis, together with daily fridge/freezer checks. Risk assessments for the home, for both Fire and Health & Safety, were updated in January 2006. Abbotts Lodge DS0000007166.V293145.R01.S.doc Version 5.1 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 3 2 3 3 2 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 2 33 3 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 2 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 2 3 3 3 1 3 3 2 X Abbotts Lodge DS0000007166.V293145.R01.S.doc Version 5.1 Page 33 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 YA9 Regulation 13(4) Requirement A new risk assessment, (covering the risk of falls, and any attendant risks) must be completed with a service user who was recently hospitalised following a fall at the home. A copy of the risk assessment must be forwarded to the CSCI. The home’s medication policy must include a section covering the storage and administration of homely remedies. The registered manager must ensure that staff undertake training in loss and bereavement, with reference to the support needs of service users. The previous time-scale not met as of the date of this inspection. The induction programme for each new staff member must be evidenced with an DS0000007166.V293145.R01.S.doc Timescale for action 30/06/06 2 YA20 13(2) 30/09/06 3 YA21 12(1)(a) 18(1)(c)(i) 18/05/06 4 YA31 18(1)(a) & (c) 30/09/06 Abbotts Lodge Version 5.1 Page 34 induction checklist. This must be kept on the staff file and should evidence the progress made in completing the Home’s induction programme. This must identify the list of components in the induction programme (training, learning tasks, familiarity with key policies/procedures etc) and, for each component, include the date when this is completed, together with the signature of the staff member and that of the responsible supervisory person. 5 YA32 18(1)(a) & (c) The registered person must ensure that all staff attend training relating to the needs of service users who have learning difficulties. Previous time-scale not met. The registered person must ensure that all staff attend training relating to service users who present challenging behaviour. Previous time-scale not met. 30/09/06 6 YA32 18(1)(a) & (c) 30/09/06 7 YA35 18(1)(a) & (c) The registered person 30/09/06 must compile a checklist of training undertaken by each staff member. This must be placed on his or her staff file. The training checklist must detail all staff training Abbotts Lodge DS0000007166.V293145.R01.S.doc Version 5.1 Page 35 required, together with the date(s) when each training course has been completed or updated. 8 YA36 12(1)(a)(b), 18(2) Staff appraisals must provide full information 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. 9 YA39 24(1)(a)(b) 21(3) The registered manager must develop questionnaires so as to obtain the views of service users’ relatives, friends, professionals and other stakeholders, regarding the quality of care and support services provided by the home. The questionnaire for service users must be developed so as to enable reasons to be given for any yes/no answers. The questionnaire must be developed in a pictorial form (using makaton). A Development Plan must be put in place for 2005/06. 30/09/06 31/12/06 10 YA39 24(1)(a)(b) 21(3) 30/09/06 11 YA39 24(1), (2) & (3) 31/10/06 Abbotts Lodge DS0000007166.V293145.R01.S.doc Version 5.1 Page 36 This should draw on the views expressed in surveys with service users, relatives/friends, professionals and other parties, and provide an indication of the extent to which the home’s aims and objectives are being met. Priorities and targets for the year ahead, to address any deficiencies or service developments required, should be identified. A copy of the report must be made available to all stakeholders, and a copy forwarded to the CSCI. The registered person must ensure that an upto-date food hygiene inspection is undertaken within the revised timescale. (Previous time-scale not proved possible to meet due to Environmental Health time-scales for inspections). 12 YA42 13(4)(a) & (c) 31/03/07 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 YA36 Good Practice Recommendations 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. DS0000007166.V293145.R01.S.doc Version 5.1 Page 37 Abbotts Lodge Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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