Inspection on 30/11/05 for Abbotts Lodge

This inspection was carried out on 30th November 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 10 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 18/05/06

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 Unannounced Inspection 30th November 2005 9:30 Abbotts Lodge DS0000007166.V265494.R01.S.doc Version 5.0 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.V265494.R01.S.doc Version 5.0 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.V265494.R01.S.doc Version 5.0 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.V265494.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th May 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 home’s 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.V265494.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted over one half day. This involved discussion with the registered manager, staff on duty and with all five of the home’s service users. There is currently one vacancy. The inspector also examined policies, procedures, service user and staff records, and other documentation relating to the management and running of the home. The inspector noted that … of the requirements identified in the previous inspection report have not, as yet, been met. As a result of this inspection, there are 10 requirements and 2 recommendations. Of the 10 requirements, there are 8 outstanding requirements from the previous inspections, 3 of which have been nearly met. The revised time-scales are highlighted in bold italics on the requirements list. 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. Service users admitted to the home have been fully assessed and know that their individual needs will be met. Review of service users’ plans is taking place, with plans being updated as required. 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 being appropriately consulted and supported to participate fully in their daily activities and routines. Service users are being assessed regarding potential risks to their health and safety, and are enabled to take responsible risks wherever possible. Service users can be assured that information about them is handled appropriately and that confidentiality is being respected. 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. Abbotts Lodge DS0000007166.V265494.R01.S.doc Version 5.0 Page 6 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. 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. Service users are being protected by the home’s medication policy and procedures, and by the provision of accredited medication training for care staff. The home’s adult protection policies and procedures are protecting service users and providing a safe environment in which to live. Service users are being protected by the home’s recruitment policy and procedures. 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. What has improved since the last inspection? Information for service users, contained within the Statement of Purpose and Service User Guide, is being reviewed annually. Abbotts Lodge DS0000007166.V265494.R01.S.doc Version 5.0 Page 7 A separate record is now being maintained for all receipts and disposals of medication. All but one staff member have completed accredited medication training. All but one staff member have now completed Vulnerable Adult protection training. Staff have received updated training in Fire Safety. All staff are now receiving regular, one-to-one supervision. All staff have received updated training in Food Hygiene. What they could do better: Each service user is provided with a service user agreement. This is not, however, being written in a format that is appropriate to the communication needs of service users living at the home. 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. The home has a complaints policy and procedure in place. This requires some amendment to ensure that the complaints procedure is open and accessible, and is not restricting in any way. Generally, service users have their needs well met by an appropriately trained and qualified staff group. There are, however, unmet training needs which must be prioritised for work with this service user group. 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. Abbotts Lodge DS0000007166.V265494.R01.S.doc Version 5.0 Page 8 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.V265494.R01.S.doc Version 5.0 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.V265494.R01.S.doc Version 5.0 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): 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. Service users admitted to the home have been fully assessed and know that their individual needs will be met. Review of service users’ plans is taking place, with plans being updated as required. Each service user is provided with a service user agreement. This is not, however, being written in a format that is appropriate to the communication needs of service users living at the home. EVIDENCE: Standards 1, 3, 4 and 5 assessed. 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 are written in a user-friendly format, and provide the information listed in the Regulations and National Minimum Standards. These documents have been recently reviewed, and are signed and dated. The inspector examined a sample of service users files and evidenced full assessments by their Local Authority Care Managers. In addition to the Abbotts Lodge DS0000007166.V265494.R01.S.doc Version 5.0 Page 11 assessments provided by the Care Manager, the home completes its own detailed assessment (based on functional performance) and risk assessment. The risk assessment format has been revised to provide a more generic assessment of risk. Twelve-monthly care management reviews were evidenced, though it was noted that these were last held in December 04/January 05, and are now due to be held again. Review of service users’ plans is taking place, with plans being updated as required. The owner/manager stated that any potential service user is invited to visit the home and meet service users and staff, 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 3-month trial period prior to a 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. The home’s service user agreement is not, however, written in an accessible form, and must be compiled in a format that is appropriate to the communication needs of service users living at the home. Abbotts Lodge DS0000007166.V265494.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 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 being appropriately consulted and supported to participate fully in their daily activities and routines. Service users are being assessed regarding potential risks to their health and safety, and are enabled to take responsible risks wherever possible. Service users can be assured that information about them is handled appropriately and that confidentiality is being respected. EVIDENCE: Standards 6, 8, 9 and 10 assessed. Abbotts Lodge DS0000007166.V265494.R01.S.doc Version 5.0 Page 13 The registered manager understands that each service user living in the home must have a community care plan review at least once every six months, and more frequently when there is any significant change in the service user’s circumstances (as detailed in standard 6.10). Also, that the Plan must be reviewed with the service user, his/her relative(s), representatives and any significant professionals including the care manager and day centre key worker. 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. 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. There are regular monthly service user meetings, the minutes of which evidence consultation on a wide range of issues relating to service users’ daily lives and the running of the home. The inspector spoke at length to a group of four (of the five) service users. They indicated that they feel involved in the day-to-day routines of the home, and that they have the opportunity to pursue individual interests and hobbies. 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 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. The home has policies and procedures in place covering Data Protection and Confidentiality; and the home is registered under the Data Protection Act. Staff training covering Data Protection and Confidentiality is included in the staff induction programme, with guidance being given on the need to balance confidentiality with a need to share relevant information when the need arises. Information relating to service users is kept in lockable filing cabinets. Abbotts Lodge DS0000007166.V265494.R01.S.doc Version 5.0 Page 14 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): 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. 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. 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. EVIDENCE: Standards 12, 14, 16 and 17 assessed. Abbotts Lodge DS0000007166.V265494.R01.S.doc Version 5.0 Page 15 The inspector discussed with service users the types of activities that they enjoy, and the opportunities for social contact. This indicated that service users enjoy a varied range of activities, both at the day centre and in their daily living at the home. One service user indicated that he enjoys ten-pin bowling, and is occasionally able to visit a local indoor bowls centre. He also indicated that he enjoys his work in open employment at a local garden centre. 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 able to develop domestic living skills, such as cleaning and keeping their room tidy, cooking (under supervision), setting table, and helping to maintain the garden. Holidays were also discussed, with service users mentioning that they had enjoyed a short holiday break (with their key workers) at a holiday centre in Hayling Island. This provided the opportunity for entertainment, and for pursuing indoor and outdoor activities, and had proved popular. Service users spoken to by the inspector indicated that they felt able to exercise a considerable degree of choice in their day-to-day lives and did not express any feelings of being unduly restricted. The philosophy of the home is to enable service users to be enabled to be as independent as possible within the constraints associated with their disabilities. Any restrictions (based on risk assessments) are detailed in the Service User Plans. Service users 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. 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 two-week period. These seemed to offer a balanced, nutritious and varied range of food. One service user who is a vegetarian is provided with vegetarian or fish options. Abbotts Lodge DS0000007166.V265494.R01.S.doc Version 5.0 Page 16 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): 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: Standards 20 and 21 assessed. The home has appropriate medication policy and procedures in place. The home uses the Monitored Dosage System for administering medication. A requirement relating to medication remains to be fully met from the previous inspection; one staff member still needs to undertake accredited medication training. Another requirement, for a separate record to be maintained for all receipts and disposals of medication, has been met. The inspector spoke with a staff member who said that she had recently undertaken training in bereavement and loss. She stated that she found this training to have been very empowering in raising her awareness of these Abbotts Lodge DS0000007166.V265494.R01.S.doc Version 5.0 Page 17 issues and how best to provide support to service users who experience loss. She cited her experience of supporting one service user in the home whose father had recently died, and for whom the sense of loss was very great. With the training she had received she had felt better equipped to empathise with and support the service user involved. The inspector discussed the need for this training to be extended to all members of staff, this being a requirement from the last inspection; the manager/owner advised that staff have been placed on Sutton’s waiting-list for training. Abbotts Lodge DS0000007166.V265494.R01.S.doc Version 5.0 Page 18 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): Service users are protected from abuse and live in a safe environment. For this level of protection to be maintained, training in adult protection must be extended to all staff. The home has a complaints policy and procedure in place. This requires some amendment to ensure that the complaints procedure is open and accessible, and is not restricting in any way. EVIDENCE: Standard 22 assessed. No adult protection issues were identified, though one requirement for statutory adult protection training remains to be fully met. The complaints procedures and information given to service users provides details as to how, and to whom they should complain, and is fairly comprehensive. Following a requirement from the last inspection, the complaints procedure has been updated so as to clarify aspects of the process. Another clause still, however, needs to be included, so as to make clear that independent advocacy, and/or communication support, can be arranged if the service user requires this. The summary of the procedure contained in the Statement of Purpose or Service User Guide must be revised in line with this amendment. Abbotts Lodge DS0000007166.V265494.R01.S.doc Version 5.0 Page 19 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): EVIDENCE: All standards were assessed and met at the last inspection. The home presented as clean, hygienic and comfortable throughout, and to be meeting the needs of the home’s service users. Abbotts Lodge DS0000007166.V265494.R01.S.doc Version 5.0 Page 20 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): Generally, service users have their needs well met by an appropriately trained and qualified staff group. There are, however, unmet training needs which must be prioritised for work with this service user group. Service users are being protected by the home’s recruitment policy and procedures. Service users can be assured that their needs are being safeguarded, through staff being appropriately supported, and supervised on a regular basis. EVIDENCE: Abbotts Lodge DS0000007166.V265494.R01.S.doc Version 5.0 Page 21 Standards 32, 34 and 36 assessed. While staff are evidenced to have relevant qualifications, skills and experience with which to deliver the services and care which the home aims to provide, there are unmet training needs which have been prioritised for work with this service user group. Following a requirement from the last inspection, staff have been placed on LB Sutton’s waiting list for training relating to the needs of service users who have learning difficulties, and for training which relates to service users who present challenging behaviour. The manager/owner advised that dates in February 2006 have been scheduled for both these training courses. 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. The manager/owner advised that no staff have been recruited since the last inspection. The inspector examined staff supervision files and evidenced that staff are now receiving regular two-monthly one-to-one supervision. The supervision format has had some revision, but requires further changes in order to provide a fuller record of the issues raised and actions/decisions agreed. An agenda should be included, with more space for each item so as to provide fuller details of what was 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. A recommendation applies. There is an outstanding requirement in respect of staff appraisal. The registered provider/manager must ensure that all staff who work at the home receive an annual appraisal (standard 36.5). This must review a staff member’s performance against the job description, and agree development and learning objectives for the year ahead. The inspector discussed the need for the appraisal format to include details regarding the staff member’s performance over the year, and to identify what training has been completed. Work objectives including training and development needs must be identified for the year ahead. An appraisal preparation form, for each staff member to self-evaluate their own performance and training/development needs should be completed prior to the appraisal session taking place. A recommendation applies. Abbotts Lodge DS0000007166.V265494.R01.S.doc Version 5.0 Page 22 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): 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. EVIDENCE: Standards 37 to 39, and 41 assessed. 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. Abbotts Lodge DS0000007166.V265494.R01.S.doc Version 5.0 Page 23 The atmosphere in this small group home is evidenced as being open, positive and inclusive. Discussion with the service users indicate that the home is being competently managed and that service users feel consulted and fully involved in decisions affecting 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 and is not, however, suitable for service users who have significant communication difficulties. A more appropriate format (using Makaton) needs to be developed. 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 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. 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. Records listed in Schedule 3 of the Regulations, relating to the safety and welfare of service users, were checked on the previous inspection. These include fire safety, medication, money, accidents, and incidents records, and were found to be up-to-date and in good order. Abbotts Lodge DS0000007166.V265494.R01.S.doc Version 5.0 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 X 3 X 2 Standard No 22 23 Score 2 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X 3 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X X X X LIFESTYLES Standard No Score 11 X 12 3 13 X 14 3 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X 2 X X 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Abbotts Lodge Score X X 2 2 Standard No 37 38 39 40 41 42 43 Score 3 3 1 X 3 2 X DS0000007166.V265494.R01.S.doc Version 5.0 Page 25 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 YA5 Regulation 5(1)(b) & (c) Requirement Timescale for action 31/03/06 2 YA20 18(1)(c) 3 YA21 12(1)(a) 18(1)(c)(i) 4 YA22 22(2) The home’s service user agreement must be compiled in a format that is appropriate to the communication needs of service users living at the home. Training in administering 31/03/06 medication must be extended to all staff, from a pharmacist accredited to provide training (All but one staff member have completed this). The registered manager must 31/03/06 ensure that staff undertake training in loss and bereavement, with reference to the support needs of service users. The complaints policy and 31/03/06 procedure must make clear: That independent advocacy and/or communication support, on behalf of the service user, in assisting him/her to raise a complaint, can be arranged if this is required. The summary of the complaints procedure contained in the Statement of Purpose and Abbotts Lodge DS0000007166.V265494.R01.S.doc Version 5.0 Page 26 5 YA23 6 YA32 7 YA32 8 YA36 9 YA39 10 YA42 Service User Guide must be revised in line with this amendment. 13(6) The registered person must ensure that all staff attend Vulnerable Adult protection training. (All but one staff member have completed this). 18 (1)(a) & The registered person must (c) ensure that all staff attend training relating to the needs of service users who have learning difficulties. 18 (1)(a) & The registered person must (c) ensure that all staff attend training relating to service users who present challenging behaviour. 12(1)(a)(b) The registered person must 18(2) ensure that all staff receive an annual appraisal. (See also recommendation). 24(1)(a)(b) The registered manager must 21(3) ensure that Quality Assurance monitoring includes the use of questionnaires. These should seek to obtain the views of service users (using Makaton), relatives, friends, professionals and other stakeholders. regarding the quality of care and support services provided by the home. 13(4)(a) & The registered person must (c) ensure that an up-to-date food hygiene inspection is undertaken. 31/03/06 31/03/06 31/03/06 31/03/06 31/03/06 31/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Abbotts Lodge DS0000007166.V265494.R01.S.doc Version 5.0 Page 27 1 YA36 2 YA36 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. An appraisal format and appraisal preparation form should be compiled for the purpose of staff appraisals. The appraisal format should include details of the staff member’s performance over the year, and identify what training has been completed. Work objectives including training and development needs must be identified for the year ahead. An appraisal preparation form, for each staff member to self-evaluate their own performance and training/development needs should be completed prior to the appraisal session taking place. Abbotts Lodge DS0000007166.V265494.R01.S.doc Version 5.0 Page 28 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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