Inspection on 05/05/05 for Abbotts Lodge

This inspection was carried out on 5th May 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 no outstanding requirements from the previous inspection report, but made 15 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 30/11/05

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 Announced Inspection 5 May 2005 9:30am The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Abbotts Lodge G53 S7166 AbbottsLodge V181125 050505 stage4 .doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Abbotts Lodge Address 56 Abbotts Road, Cheam, Surrey, SM3 9TA Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8395 9052 020 8286 4067 Mr Mohamad and Mrs Bibi Hoozeer Mr Mohamad Hoozeer Care Home 6 Category(ies) of Learning Disability (6) registration, with number of places Abbotts Lodge G53 S7166 AbbottsLodge V181125 050505 stage4 .doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: none Date of last inspection 7 October 2004 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 G53 S7166 AbbottsLodge V181125 050505 stage4 .doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection was conducted over one day and involved discussion with the registered manager, staff on duty and service users. The inspector noted that 7 of the requirements identified in the previous inspection report have not, as yet, been met. There are 8 new requirements and 2 recommendations from this inspection. All of the requirements were discussed and agreed at the time of the inspection with the registered manager. What the service does well: 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. This was evidenced on this inspection. The home was able to demonstrate that the assessed needs of individuals admitted to the home are being met. Service users spoken to by the inspector expressed their satisfaction with the care provided, and service users presented as well cared for and supported. Service users feel that their needs are being met, and that they are able to participate fully in decisions that affect them and their day-to-day lives in the home. Service users’ needs are being recorded appropriately in care plans. These now include a list of clients’ likes and dislikes. Prospective service users are provided with the information they need to make an informed choice. The home has a Statement of Purpose and a Service User Guide. These are written in a user-friendly format. Service users are encouraged and supported to develop an independent lifestyle, and are risk assessed for areas of risk in their daily activity. Staff members on duty were observed to work with service users in an enabling and client-centred way. Service users indicated that they are able to make choices in their day-to-day routines and activities and are consulted regarding decisions that affect them. Abbotts Lodge G53 S7166 AbbottsLodge V181125 050505 stage4 .doc Version 1.30 Page 6 Service users are provided with a range of opportunities for recreational and social activities, and for participating in the local community. There was evidence, among service users, of a broad level of satisfaction with the home and the opportunities offered for personal development and leisure activity. Service users feel that they are supported by staff in enabling them to exercise choice and control in their daily routines, and were observed to have good relationships with the management and staff. Those users spoken to by the inspector indicated that they are encouraged to maintain contact with family and friends, and that their privacy for receiving visitors is respected. Service users’ personal support and health care needs are evidenced to be well met in this home, with support being planned according to the individual needs presented. Staff observed on the inspection presented as caring and supportive towards the service users, and to be interacting in a positive way. Service users are evidenced to live in a safe, hygienic and well-maintained environment with access to appropriate and sufficient communal facilities. Service users’ rooms are observed to be safe, comfortable and pleasantly decorated, being suited to individual needs. . What has improved since the last inspection? Following a concern identified at the last inspection, service users care plans are now being reviewed on a six-monthly basis. Accredited training in medication has been provided to all but one member of staff. Two health and safety concerns have been addressed, one relating to the repositioning of a potentially dangerous light fitting in a service user’s bedroom, the other being the completion of a legionella check for the home’s water supply. Abbotts Lodge G53 S7166 AbbottsLodge V181125 050505 stage4 .doc Version 1.30 Page 7 Training in loss and bereavement has been provided for 3 of the 6 staff. Staff meetings are now being held on a regular, monthly basis. What they could do better: While the home is able to demonstrate that it can meet the range of needs presented by service users, staff need to develop their skills and awareness in working with individuals who have learning difficulties. While there are appropriate induction and training programmes in place, staff need to undertake updated training relating to the needs of adults with learning difficulties. A clear format for the recording of receipts and disposals of medication needs to be put in place. Accredited medication training has been provided to all but one member of staff. Issues relating to bereavement and loss are evidenced as being dealt with appropriately. Relevant training designed to raise awareness of these issues needs, however, to be extended to all staff. The home is evidenced to provide a safe and caring environment for its service users, with appropriate protection policies and procedures being in place. There is a need, however, for staff awareness of adult protection issues to be raised. In this regard, training in adult protection needs to be extended to all staff at the home. 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. While the home has appropriate recruitment policy and procedures in place, previous concerns indicate a need for the home to be vigilant in ensuring that all recruitment checks are being satisfactorily completed. The registered manager needs to demonstrate that staff are being appropriately supported through regular supervision, with annual appraisal of their performance and development taking place. Service users meetings should be recorded so as to include an adenda, discussion of each issue, and actions agreed. The names of service users and staff who attend should be noted. The supervision format should be revised so as to provide more space for each item discussed. The supervision record Abbotts Lodge G53 S7166 AbbottsLodge V181125 050505 stage4 .doc Version 1.30 Page 8 should be signed and dated at the bottom of the record sheet rather than for each item discussed as at present. Whilst views expressed to the inspector from service users and staff were generally positive, the home needs to evidence its performance and develop its quality assurance processes. The views of service users, relatives/friends, professionals and other visitors need to be elicited and an annual quality audit report compiled. Generally, the health, safety and welfare of staff are being appropriately protected. Updated training is, however, required for food hygiene and fire safety. 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 G53 S7166 AbbottsLodge V181125 050505 stage4 .doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Abbotts Lodge G53 S7166 AbbottsLodge V181125 050505 stage4 .doc Version 1.30 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 standard(s) 1, 2, and 3 Prospective service users are provided with the information they need to make an informed choice. This information contained in the Statement of Purpose and Service User Guide must be reviewed annually. Service users admitted to the home have been fully assessed and know that their individual needs will be met. Service users care plans are now being reviewed six-monthly. The home needs to 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. EVIDENCE: 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. All service users are given a copy of the Service User Guide. The SOP and SUG need to be signed and dated, and the date for the next 12 monthly Abbotts Lodge G53 S7166 AbbottsLodge V181125 050505 stage4 .doc Version 1.30 Page 11 review of these documents inserted. This is an unmet requirement from the last inspection. Following a requirement from the last inspection, the Complaints Procedure in the Service User Guide has been amended so as to make clear that the service user, his relative or representative can, if they so wish, complain directly to the CSCI at any time. The summary of the Complaints Procedure needs, however, to be amended in line with the alterations required in Standard 22. No new service users have been admitted since the last inspection. There is currently a vacancy, one service user having moved into independent living accommodation. Inspection of service users’ files indicates that service users are admitted following full assessments by their Local Authority Care Managers. In addition to the assessments provided by the Care Manager, the home completes its own detailed assessment (based on functional performance) and risk assessment. 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 additional assessment formats have been put in place in respect of Vulnerability, Risk-taking, Aggression and Verbal Abuse, providing a very comprehensive assessment of each service user. The home needs to demonstrate that the range of needs presented by service users are being fully addressed. The inspector spoke to service users, who expressed positive feelings about the home and the ability of staff to meet their needs. Staff members were seen to be interacting well with service users, and to be enabling in their attitudes and actions. Staff are generally evidenced to have the qualifications, skills and experience with which to deliver the services and care which the home aims to provide. There is, however, a need for staff to undertake specific, updated training relating to work with service users who have learning difficulties, and for training in challenging behaviour. A requirement is made in respect of Standard 33 (Staffing). This will need to be addressed before it can be demonstrated that this standard (3) is fully met. Following a requirement from the previous inspection there has been a significant improvement in the review of service users’ care plans. The inspector found that community care plan reviews are now being held 6 monthly, though one service user’s review is slightly overdue having last been reviewed on 13/10/04. Abbotts Lodge G53 S7166 AbbottsLodge V181125 050505 stage4 .doc Version 1.30 Page 12 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. Abbotts Lodge G53 S7166 AbbottsLodge V181125 050505 stage4 .doc Version 1.30 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 standard(s) 6, 7, and 9 Service users needs are appropriately recorded and met, with service users being enabled to participate fully in decisions that affect them and their dayto-day lives in the home. Service users are encouraged and supported to develop an independent lifestyle, with risk assessments being carried out for activities which involve responsible risk-taking. EVIDENCE: The inspector examined three case files and found these to include detailed Care Plans, guidance and risk assessments. Care Plans now 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 confirmed that each service user has been given a copy of these. The registered manager stated that formal reviews, with either the Care Manager or Day Centre keyworker present, are now being held six monthly. This was confirmed from the inspection of three service user case files. The home aims to assist service users to develop self-confidence and to make decisions regarding their day-to-day activity and living. The support and Abbotts Lodge G53 S7166 AbbottsLodge V181125 050505 stage4 .doc Version 1.30 Page 14 guidance of the manager and staff are provided to ensure that service users are involved in making decisions which are in their best interests. One service user, with the support of the home and his care manager, has recently fulfilled his wish to move into independent living accommodation. Restrictions on service users’ rights are only made where there is a high level of risk attached, with these being subject to risk assessment, and being recorded in the service user plan. The home supports service users in looking after their own monies, with records being kept of all transactions. Staff members on duty were observed to work with service users in an enabling and client-centred way. Service users spoken to by the inspector indicated that they are able to make choices in their day-to-day routines and activities and are consulted regarding decisions that affect them. Service user involvement was evidenced in service user plans, and review notes. 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. The manager has advised the inspector that service users are risk assessed for areas of risk in their daily activity and that service users have a range of opportunities for responsible risk taking. For example, service users draw their own money, travel without assistance, and assist with cooking. The inspector examined a number of service users’ care plans and risk assessments. These evidenced that risks had been identified and noted, with risk-taking strategies having been put in place. Abbotts Lodge G53 S7166 AbbottsLodge V181125 050505 stage4 .doc Version 1.30 Page 15 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 12, 13, 14 and 15. 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. EVIDENCE: Abbotts Lodge G53 S7166 AbbottsLodge V181125 050505 stage4 .doc Version 1.30 Page 16 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. Service users were 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, selfadvocacy, and independent/social living skills. One service user is undertaking a computer course, while another has open employment in a 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. One service user was observed to be assisting a staff member to make sandwiches following her return from the day centre. The inspector spoke to four of the five service users. There was a broad level of satisfaction with the home and the opportunities offered for personal development and leisure activity. Three of the service users said that they attend the day centre, indicating that they greatly enjoyed the social contact and activities offered there. The other service user said that she was not really interested in attending the day centre and indicated that she derived enjoyment from pursuing more individual interests and learning, and from her contact with friends and family. Service users have opportunities to participate in the local community, going shopping and attending church and church events, and visiting leisure centres. The manager advised that service users are encouraged to access community resources, with support being provided when this is required. Service users 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. Two of the service users said that they would be going to the club that evening where there was to be a Bring and Buy Sale. The home was evidenced to encourage service users to maintain family links and friendships both inside and outside of the home. Service users are able to see visitors in the privacy of their own rooms. Some of the service users are able to go and stay with family for day or weekend visits. Service users spoken to by the inspector indicated that they are encouraged to maintain contact with family and friends, and that their privacy for receiving visitors is respected. The home organises day outings to places of interest, there having been a recent day trip to Rochester, which service users indicated that they had greatly enjoyed. The home has its own transport. A week’s holiday to a holiday centre in Hayling Island is being organised in July 2005 which some of the Abbotts Lodge G53 S7166 AbbottsLodge V181125 050505 stage4 .doc Version 1.30 Page 17 service users were able to previously visit at Christmas, and said had gone well. There was evidence that service users are able to exercise choice and control in their daily routines and activities. The daily routines identified in service users’ case files, and in discussion with staff and service users, did not indicate any unnecessary restriction of service users freedom of movement or choice, any constraints (based on risk assessments) being detailed in the Service User Plans. Service users spoken to by the inspector indicated that they had the freedom to exercise choice within and outside of the home, and did not express any feelings of being unduly constrained in their day-to-day activity. Abbotts Lodge G53 S7166 AbbottsLodge V181125 050505 stage4 .doc Version 1.30 Page 18 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19, 20 and 21 The health, personal and social care needs of service users are being fully met, and their privacy respected. A clear format for the recording of receipts and disposals of medication needs to be put in place. Accredited medication training has been provided to all but one member of staff. 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: 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. Service users indicated that they feel well supported by staff and that their privacy and independence is respected. Abbotts Lodge G53 S7166 AbbottsLodge V181125 050505 stage4 .doc Version 1.30 Page 19 Service user files inspected evidence records of service users’ contact with health agencies. This includes local GPs, dentists, a visiting optician, and a monthly visit from a Psychiatrist. Where appropriate, service users are assisted to manage their weight through a “healthy eating” program. The registered manager demonstrated an awareness of the healthcare needs of the service users, and this is evidenced in the home’s records and procedures. 2 of the 5 service users require medication, neither of whom have been assessed as being able to self-administer. The home maintains MAR sheets for administering medication. These were in order. The home uses the Monitored Dosage System for administering medication. At present receipts and disposals of medication are recorded in the service user’s care notes. A requirement is made for a separate record to be maintained for all receipts and disposals of medication. The home provides training for staff who administer medication. A requirement from the previous inspection for accredited medication training to be provided for care staff has been addressed. Staff attended LB Sutton’s ‘Care of Medicines’ training for residential care on 19/1/05. One member of staff still needs to undertake this training, hence the requirement remains. A requirement from the previous inspection for staff to receive training in loss and bereavement has been partly met. The manager advised that 3 of the 6 staff have attended this training, and the others are scheduled to go on a future course. The inspector spoke to a staff member on duty who has attended this training. She indicated that this had been helpful in increasing her awareness of the bereavement process, and in helping to support a service user who has recently lost his father. Abbotts Lodge G53 S7166 AbbottsLodge V181125 050505 stage4 .doc Version 1.30 Page 20 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 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: There have been no complaints since the last inspection on 17/5/04. 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. In line with a requirement from the last inspection, the complaints procedure has been amended to make clear that the service user, his relative or representative can, if they so wish, complain directly to the CSCI (Commission For Social Care Inspection) at any time. The Complaints Procedure requires further amendment, for which a requirement is made. Abbotts Lodge G53 S7166 AbbottsLodge V181125 050505 stage4 .doc Version 1.30 Page 21 The procedure must make clear that complaints can be made ‘verbally’ by the complainant as well as ‘being put in writing’. Where possible, a verbal complaint should be confirmed in writing. It must make clear that a complaint can be raised with the manager at any stage. Reference to raising the complaint with the person’s ‘immediate superior’ is inappropriate and should be removed. Another clause should be added to 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 procedure contained in the Statement of Purpose or Service User Guide must be amended in line with these amendments. 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 confirmed that all staff are being provided with a summary of the home’s procedures for the protection of vulnerable adults. The inspector was informed that 5 of 6 staff members have completed Sutton’s multi-agency Adult Protection training (on 16/12/04). This requirement remains to be fully met. Abbotts Lodge G53 S7166 AbbottsLodge V181125 050505 stage4 .doc Version 1.30 Page 22 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 26, 27, 28, 29 and 30 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: 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 accommodation needs of the service users are evidenced to be reasonably well met. The lounge and adjoining conservatory ‘dining area’ have had new light coloured wooden flooring laid down, replacing the previous lino and carpeting. Abbotts Lodge G53 S7166 AbbottsLodge V181125 050505 stage4 .doc Version 1.30 Page 23 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. A requirement from the previous inspection, relating to the need for a main light fitting in the shared double bedroom to be repositioned so as to be clear of the dividing petition curtain, has been met. While there is no private room for visitors, the dining area in the conservatory (which adjoins the lounge) has petition doors and can be used for this purpose, though privacy cannot be guaranteed. 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 current service users do not require adaptations or aids and they are able to move freely around the premises, including the ground and first floors, and the front and rear gardens. Service users spoken to by the inspector indicated that they were happy with the facilities provided and that their accommodation needs are being met. The home was observed to provide a pleasant and homely environment in which to live. One service user showed the inspector his room which was pleasantly decorated and arranged, and which he indicated met his personal needs The home presented as clean and hygienic throughout and there were no hygiene concerns. The home has a small laundry which seems adequate for the purpose. Service users themselves assist in helping to maintain the high standards observed in the home. Abbotts Lodge G53 S7166 AbbottsLodge V181125 050505 stage4 .doc Version 1.30 Page 24 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 35 and 36 While the home has appropriate induction and training programmes in place, with staff having relevant qualifications and skills, there are unmet training needs which must be prioritised for work with this service user group. While the home has appropriate recruitment policy and procedures in place, previous concerns indicate a need for vigilance in ensuring that all recruitment checks are being satisfactorily completed. The registered manager needs to demonstrate, through regular supervision and annual appraisal, that staff are being appropriately supported and supervised. EVIDENCE: Abbotts Lodge G53 S7166 AbbottsLodge V181125 050505 stage4 .doc Version 1.30 Page 25 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 must be prioritised for work with this service user group. Staff must, as a high priority, undertake updated training relating to the needs of service users who have learning difficulties, and training which relates to service users who present challenging behaviour. These requirements must be met within the set time-scales. To ensure that all new and existing staff feel properly and fully supported in understanding their own and others roles and responsibilities, in meeting the home’s objectives, it is essential that regular, formal supervision is held. Following a requirement from the previous two inspections, the registered provider/manager failed to meet the time-scale set for meeting this, and has only recently started to provide one-to-one supervision with staff. This was evidenced with staff supervision notes from 25/4/05. For this requirement to be met the provider must demonstrate that staff are receiving regular formal supervision at least six times a year as prescribed in standard 36.4. This will be need to be monitored on forthcoming inspections. The inspector examined the supervision format and recommends that this is revised so as to provide more space for each item to be covered. The supervision record should be signed and dated once at the bottom of the record sheet rather than for each item discussed as at present. 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. This is made a requirement. The home’s recruitment policy and practice are evidenced to have been more rigorously observed. In the light of a concern identified at the last inspection, and detailed below, this needs to be closely monitored on future inspections. The manager advised that no new staff members have been recruited since the last inspection. Inspection of staff files has evidenced that the registered manager is ensuring that all staff recruited have had up-to-date CRB (Criminal Records Bureau) and POVA (Protection of Vulnerable Adults) checks in place. A concern relating to the need for a POVA check and two written references to be provided, for a staff member recruited prior to the last inspection, has been resolved with the staff member concerned having left the home’s employ. The registered manager confirmed his understanding of the need for the POVA check and two written references to be obtained before making any future staff appointments. Abbotts Lodge G53 S7166 AbbottsLodge V181125 050505 stage4 .doc Version 1.30 Page 26 Abbotts Lodge G53 S7166 AbbottsLodge V181125 050505 stage4 .doc Version 1.30 Page 27 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39 and 42 The registered manager needs to demonstrate, through quality assurance processes, that the home is being run in the best interests of service users. Generally, the health, safety and welfare of staff are being appropriately protected. Updated training is required for food hygiene and fire safety. EVIDENCE: Quality assurance arrangements currently include meetings with service users, staff, relatives and professionals. A requirement from the previous inspection remains to be met. The home must develop questionnaires (in a suitable format) so as to obtain the views of service users, together with questionnaires for other groups (relatives, friends, professionals), regarding their views as to the services provided by the home and where improvements could be made. Abbotts Lodge G53 S7166 AbbottsLodge V181125 050505 stage4 .doc Version 1.30 Page 28 A further requirement also remains to be met. A Quality Assurance audit with an annual development plan for the home must be put in place. This needs to bring together all the information gathered from meetings, surveys and other types of feedback, and to identify those areas where the aims and objectives of the home are not being met and the actions/plans required to address any deficiencies. A copy of the report should be made available to service users, their representatives and other parties, and a copy should be forwarded to the CSCI (Commission for Social Care Inspection). A requirement from the previous inspection, relating to the safe positioning of a main light fitting in a shared bedroom has now been met. In all other respects the home presented well, having full regard to the health, safety and welfare of service users. The inspector completed health and safety checks with updated certification having been provided for fire inspection and safety, legionella, gas, electrical installation and appliances, and environmental health. Inspections for health and safety and food hygiene are overdue, last having been completed on 8/12/03, for which a requirement is made. . Updated training is required for food hygiene and fire safety, for which requirements apply. Abbotts Lodge G53 S7166 AbbottsLodge V181125 050505 stage4 .doc Version 1.30 Page 29 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 2 3 3 x x Standard No 22 23 ENVIRONMENT Score 2 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 x x Standard No 31 32 33 34 35 36 Score 3 2 3 3 3 1 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Abbotts Lodge Score 3 3 2 2 Standard No 37 38 39 40 41 42 43 Score x x 1 x x 2 2 G53 S7166 AbbottsLodge V181125 050505 stage4 .doc Version 1.30 Page 30 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 YA1 Regulation 4 (1), 5 (1), 6 (a) 13 (4)c 18 (1)c Requirement The Statement of Purpose and Service User Guide must be signed and dated, and the date given for the next review. A separate record needs to be maintained for all receipts and disposals of medication. Training in administering medication must be provided to all staff, from a pharmacist accredited to provide training. The registered manager must ensure that staff undertake training in loss and bereavement, with reference to the support needs of service users. The complaints policy and procedure must make clear: 1. That complaints can be made ‘verbally’ by the complainant as well as ‘being put in writing’. 2. That the complaint must be raised with the registered manager. Reference to raising the complaint with the person’s ‘immediate superior’ is inappropriate and should be removed. 3. That independent advocacy Timescale for action Extended to 1 September 2005 1 September 2005 Extended to 1 September 2005 Extended to 1 October 2005 1 October 2005 2. 3. YA20 YA20 4. YA21 12 (1)(a), 18 (1)(c)(i) 5. YA22 22 (2) Abbotts Lodge G53 S7166 AbbottsLodge V181125 050505 stage4 .doc Version 1.30 Page 31 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 Service User Guide must be revised in line with these amendments. The registered person must ensure that all staff attend Vulnerable Adult protection training. The registered person must ensure that all staff attend training relating to the needs of service users who have learning difficulties. The registered person must ensure that all staff attend training relating to service users who present challenging behaviour. The registered person must ensure that staff receive updated training in fire safety. The registered person must ensure that all new and existing staff receive regular, formal supervision. The registered person must ensure that all staff receive an annual appraisal. The registered manager must complete a Quality Assurance audit and put in place an annual development plan for the home.The development plan should aim to collate all the feedback and information gathered from surveys and other sources, and identify those areas where the aims and objectives of the home are not being fully met, and the 6. 13 (6) YA23 7. 18 (1)(a) & (c) YA32 Extended to 1 September 2005 1 October 2005 8. 18 (1)(a) & (c) YA32 1 October 2005 9. 10. 18 (1)(a) & (c) 12 (1) (a) & (b)18 (2) 12 (1) (a) & (b)18 (2) 24 (1)(a) & (b), (2) & (3) YA42 YA36 1 October 2005 Extended to 1 July 2005 1 December 2005 Extended to 1 December 2005 11. 12. YA36 YA39 Abbotts Lodge G53 S7166 AbbottsLodge V181125 050505 stage4 .doc Version 1.30 Page 32 13. 24 (1)(a) & (b), & 21 (3) YA39 14. 15. 20 (5) 18 (1)(a) & (c) YA43 YA42 actions/plans proposed to address any deficiencies.A copy of the report should be made available to service users, their representatives and other interested parties. A copy should be forwarded to the CSCI (Commission for Social Care Inspection). The registered manager must 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. The owner is required to provide up to date annual accounts (year ending 2004). The registered person must ensure that staff receive updated training in food hygiene. Extended to 1 October 2005 1 December 2005 1 October 2005 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 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. Service users meetings should be recorded so as to include an adenda, discussion of each issue, and actions agreed. The names of service users and staff who attend should be noted. 2. YA 36 Abbotts Lodge G53 S7166 AbbottsLodge V181125 050505 stage4 .doc Version 1.30 Page 33 Commission for Social Care Inspection 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. Extracts may not be used or reproduced without the express permission of CSCI Abbotts Lodge G53 S7166 AbbottsLodge V181125 050505 stage4 .doc Version 1.30 Page 34 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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