Inspection on 14/05/08 for Abbottswood Lodge

This inspection was carried out on 14th May 2008.

CSCI found this care home to be providing an Adequate service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Abbottswood Lodge 03/07/07

Abbottswood Lodge 30/11/05

Abbottswood Lodge 11/07/05

Abbottswood Lodge 03/02/05

Abbottswood Lodge 06/09/04

Similar services:

Chesham House

Argyll House

Dorset Lodge

Acacia House

Falcon House

Dial House Nursing Home

Cromwell Avenue (9)

Abbey Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Abbottswood Lodge 226 Southchurch Road Southend On Sea Essex SS1 2LS Lead Inspector Ms Vicky Dutton Unannounced Inspection 14th May 2008 08:30 X10015.doc Version 1.40 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 Abbottswood Lodge DS0000015491.V364795.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. 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. Abbottswood Lodge DS0000015491.V364795.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbottswood Lodge Address 226 Southchurch Road Southend On Sea Essex SS1 2LS 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) 01702 462541 01702 462541 kaminipeters@btinternet.com Mr Eversley Peters Mrs Kamini Peters Mrs Kamini Peters Care Home 12 Category(ies) of Dementia - over 65 years of age (12), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (12) Abbottswood Lodge DS0000015491.V364795.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd July 2007 Brief Description of the Service: Abbottswood Lodge provides accommodation and personal care for up to twelve elderly people who have care needs associated with a mental disorder or dementia. All bedrooms were single and fitted with a call bell system. Bedrooms are on two floors, which were accessed by a passenger lift. There is a lounge and dining room on the ground floor. The home is privately owned and managed. Abbottswood Lodge is situated in the Southchurch area of Southend on Sea and is close to the town centre, as well as local community facilities and amenities. The home has forecourt parking facilities for 4 cars and a pleasant garden with a patio area to the rear of the property. The current charges at the home are £560.00 per week. Additional charges and costs are incurred by people for hairdressing, chiropody, transport and personal items such as toiletries, newspapers and magazines. People are also charged equally when outside entertainers are used in the home. The Home’s Statement of Purpose and Service User’s Guide are available and can be obtained from the home upon request. A copy of the last inspection report is also readily available. Abbottswood Lodge DS0000015491.V364795.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This was an unannounced ‘key’ site visit. At this visit we (CSCI) considered how well the home meets the needs of the people living there, how staff and management work to provide good outcomes for people, and how people are helped to have a lifestyle that is acceptable to them. The level of compliance with requirements made at the previous inspection was assessed. The site visit took place over a period of seven hours. A partial tour of the premises was undertaken, care records, staff records, medication records and other documentation were selected and various elements of these assessed. Time was spent talking to, observing and interacting with people living at the home, and talking to staff and visitors. Before the site visit a selection of surveys with addressed return envelopes had been sent to the home for distribution to residents, relatives involved professionals and staff. The views expressed at the site visit and in survey responses have been incorporated into this report. This site visit included a ‘thematic probe.’ This looked at how well people living in the home are safeguarded, through the home’s practices, policies and procedures. The thematic probe took place in all homes being inspected over a short period, and information gathered will form the basis for a future CSCI report. We were assisted at the site visit by the manager, and other members of the staff team. Feedback on findings was provided to the manager throughout the inspection. The opportunity for discussion or clarification was given. We would like to thank the manager, staff team, residents, relatives and visiting professionals for their help throughout the inspection process. What the service does well: People living at Abbottswood Lodge and their families are very happy with the service offered and made comments such as “I can’t fault it, I am very happy with everything.” Families felt that management and staff kept them involved with their relatives’ care and informed of any changes. Abbottswood Lodge DS0000015491.V364795.R01.S.doc Version 5.2 Page 6 Before people decide to move into Abbottswood Lodge, the manager visits them and carries out a detailed assessment. This is to make sure that their needs can be met. Visitors are always made welcome and are able to develop a good rapport with management and staff. Staff working at Abbottswood Lodge are motivated and keen to do a good job. Most staff have worked there for a number of years, and this provides familiarity and continuity for people. What has improved since the last inspection? What they could do better: Although levels of staff training are generally good there are some areas where improvement is needed, to ensure that people always receive safe care. Some staff need to be trained or updated in safe moving and handling practices. This was also raised at the previous inspection. Management need to keep CSCI better informed of things happening in the home, so that they can demonstrate an open approach and show how they manage different situations. Abbottswood Lodge DS0000015491.V364795.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Abbottswood Lodge DS0000015491.V364795.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Abbottswood Lodge DS0000015491.V364795.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People wanting to move into the home can feel confident that their needs will be met, based on a thorough assessment, and that they will have access to sufficient information about the home to help them to make an informed choice. EVIDENCE: There is a Statement of Purpose and Service Users Guide available These provide people with an adequate level of information about the home. On surveys people said that they had received enough information about the home to help them to make a decision about moving in. Due to the care needs of people moving into Abbottswood Lodge, it is generally families who visit the home and decide if it is the right place for their relative. One person said “after looking around a few homes that were suitable for my [relative], this home was by far the best.” Abbottswood Lodge DS0000015491.V364795.R01.S.doc Version 5.2 Page 10 All people considering moving into Abbottswood Lodge have their needs assessed by the manager, to ensure that the home is suitable to meet their needs. Pre admission assessments viewed on files were comprehensive. Information and assessments were also available from local authorities funding the placements. Following on from the assessment the manager had written to people summarising the assessment, and confirming that Abbottswood Lodge would be able to meet their needs. Intermediate care is not provided at Abbottswood Lodge. Abbottswood Lodge DS0000015491.V364795.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People will receive the personal and health care support they need. EVIDENCE: People spoken with and responses on surveys showed that there is a good level of satisfaction with the care offered at Abbottswood Lodge. One said “They meet my [relatives] needs very well,” and another “ My [relative] receives brilliant care and support from the care home and staff.” People living at the home who were unable to express an opinion about the service looked relaxed and well cared for. As part of this inspection a number of care plans were viewed. Since the previous inspection care planning at the home has been improved, and now provides a more person centred and holistic approach that incorporates planning for people’s social and occupational needs. The manager is in the process of refining care planning still further so that information on specific areas of care needs are more clearly highlighted. Care plans viewed provided a good basis for staff to deliver individual care to people. Although most people living in the home have communication difficulties due to their illness, care plans still demonstrated an enabling Abbottswood Lodge DS0000015491.V364795.R01.S.doc Version 5.2 Page 12 approach such as “When choosing *** clothes for the day show [them] and ask [them] what [they] would like to wear. *** may not be able to choose but offer [them] the choice.” Care plans had been regularly reviewed. Families had signed the care plans to show that they had seen, and were in agreement with them. Risk assessments were in place in relation to moving and handling, and any areas of specific need such as wandering behaviours. Again the manager is in the process of refining how risk assessments are presented so that they demonstrate a person centred rather that a checklist approach. Daily care records are kept in separate files from care plans. This practice may not encourage staff to make full use of care planning information. However staff spoken with and observations, and a staff handover attended did demonstrate that staff have a good understanding of people’s needs. Some comments were: “We are always informed of any new needs or changes in the care plans,” “Our boss is always talking to staff about how we need to do care plans and how we need to update all care plans, and the importance of having these,” and “Using the key worker systems we regularly review and update the care plans with the manager.” Daily records showed that ongoing care is recorded and monitored. However care is needed to ensure that this is consistent. For example staff not recording when personal care such as bathing has taken place, and follow through on daily records such as recording that one person is to have a urine sample taken the following day, and then no further comment being made about this. Records showed that people’s healthcare is monitored and that appropriate professionals such as psychiatric teams, district nurses and community workers are involved in providing, for and monitoring their ongoing care. One visiting professional said, “If in doubt staff members consult us for advice and support,” and “In depth discussions have taken place and consultants advice has been taken when concerns about clients care is involved.” Some staff have undertaken recent training courses in areas such as diabetes awareness and continence awareness that will further help to support people’s needs. Records showed that a chiropodist and optician visit on a regular basis. The manager said that people visit a local dentist. This was confirmed by a member of staff who said, “I took [resident] to the dentist last week, and a new set of teeth is being made.” Families felt that staff were good at keeping them informed. One person said “They always phone me if my [relative] is unwell or they have phoned a doctor,” and another “The care home always rings me immediately and keeps me informed of any changes.” A visiting professional said, “I have always been contacted by the provider if there are any concerns for this person in respect of health or social needs and have been kept up to date with the issues raised…..I can only comment on one of the service users and can say that to the best of my knowledge their healthcare needs are fully met.” Another visiting professional said “Excellent awareness of residents health needs.” People’s nutritional needs are assessed and as far as possible their weight monitored. Since the previous inspection nutrition records have been put into place and maintained. Abbottswood Lodge DS0000015491.V364795.R01.S.doc Version 5.2 Page 13 People’s medicines are managed safely. Good records are maintained, and staff have received training. Some staff last undertook medication training in 2005. The manager said that she monitors practice and that training is soon to be updated through a purchased training pack. The storage of medication needs to be reviewed to ensure that arrangements meet with current legislative requirements. It was also advised that temperatures in the storage area be monitored to ensure that people’s medicines, particularly eye drops are stored in optimum conditions. During the day staff were kind and courteous in their approach to people. Privacy was respected, and people’s dignity was thought about. For example one person being taken to have clean clothes after getting some drink down them. A relative said “staff are very pleasant and caring towards all the residents who always look clean and are dressed in matching clothes, with great care given to protect the residents dignity.” A visiting professional said that staff showed “Respect for each client’s privacy needs, and promotes clients independence.” Abbottswood Lodge DS0000015491.V364795.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a home that is seeking continued development to ensure that they enjoy a lifestyle that is suitable to meet their needs. EVIDENCE: Since the previous inspection management and staff have made a real effort, and achieved a great improvement in the level of occupation, activity and enhancement of lifestyle for people living in the home. An activities programme is in place, which is flexible to meet the wishes of people on any given day. Three staff have undertaken a two day training course in providing activities for people who have dementia. Equipment and information is available to support the provision of activity and occupation. Talking newspapers are received on a weekly basis. During the day staff were available at all times to interact with and support people. Group and individual activities were undertaken. Individual needs and preferred activities were recognised in care planning. A relative said, “As [relative] has Alzheimer’s late stage [they] are no longer able to do games/drawing etc. but the staff do spend a lot of time with [them] and [their] passion for music and dancing is still evident, so music is played for [them] and [they] just like to wander around.” Staff have found the move to providing stimulation and activity very Abbottswood Lodge DS0000015491.V364795.R01.S.doc Version 5.2 Page 15 positive and said that they had noticed real changes in people. One said, “Residents are much more alert and responsive.” Families were also pleased that this area had improved, one said, “they have made a noticeable effort to provide activities, particularly in the afternoon.” Although good progress has been made, management, staff and relatives know that more can be achieved. The manager said that arrangements are being made for a mobile library to attend. A staff member said that although work was already in progress they could “engage more in social activity.” A relative said “Although I have seen a considerable improvement in the number of activities the residents can take part in I wonder if it would be possible to involve more people from the community, perhaps people singing, people with dogs, just to stimulate the residents more.” Another felt that it would be good for people to get out more, “even for just a walk around the block.” People’s known preferences are recorded in care planning. Where people are unable to express their own wishes, their cultural and spiritual needs have been discussed with families with relevant information recorded in care plans. Visitors are always made welcome. During the site visit when people visited they were always warmly welcomed by staff and offered refreshment. One relative said that “visitors are always made to feel welcome at any time.” A visiting professional said, “When visiting I have always been offered a quiet and private area to talk to the service user.” During the day staff were sensitive to people’s needs and offered them choices and assistance. This included recognising when one person felt ready to return to bed, and asking someone else if they would like to sit in the garden for a while. Some rooms viewed were homely, and showed that people could bring their individual personal possessions into the home when they moved in. Information on advocacy services were available to people or their families could seek independent help and support if they wished to do so. People said that they enjoyed the food provided. One said, “The food is lovely here, lovely dumplings, I always have seconds.” There is a four weekly rotating menu, which showed that a good range of foods are offered. People are offered choices. During the morning of the site visit a member of staff was asking people what they wanted for lunch. The manager and staff spoken with recognised that due to people’s communication difficulties, there was a need to develop strategies such as using pictures to assist people in making choices. On surveys two people said that they ‘always’ enjoyed the meals, and two people that they ‘usually’ did. Abbottswood Lodge DS0000015491.V364795.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People can raise concerns about the service, and be confident that they will be safeguarded from abuse. EVIDENCE: People spoken with and responses on surveys showed that people know how to raise any concerns about the service and would be confident in doing so. One relative said, “If we need to first call is to staff, then manager, any problems have been sorted out very quickly.” The home’s complaints procedure is on display for people. This needs to be updated to reflect the fact that CSCI no longer take an active role in investigating specific complaints about a service, but that people can refer concerns to the local authority funding their placement who do have this role. A complaints folder viewed showed that since the previous inspection one complaint had been recorded, and managed appropriately. This site visit included a ‘thematic probe’ into how well people are safeguarded. This meant that we asked people how safe they felt at the home, looked at staffs’ training and understanding of safeguarding, and saw how policies, procedures and practice in the home help to keep people safe. The information gathered was fed back through CSCI and will be the subject of a future report looking at how well care homes perform relating to safeguarding. Training records and staff spoken with showed that most staff had received training in safeguarding, and had a good understanding of their responsibilities. The Abbottswood Lodge DS0000015491.V364795.R01.S.doc Version 5.2 Page 17 manager said that they had not updated their training for some time. Staff generally knew who they needed to contact in the event of any incident occurring. The home’s adult protection policy needs to be updated to include the relevant contact details, and to make it clear that any incident should be referred to the local safeguarding team, and not, as stated, investigated by management at the home. The local Authorities Adult protection strategy and handbook dating from 2002 was in place. The manager was advised that new guidance was now available. People felt that Abbottswood Lodge provided a safe environment for people. A relative said “It’s a very caring environment, safe and secure.” Some people living at Abbottswood Lodge can sometimes behave in ways that is challenging for staff. One visiting professional felt that one of the things the home did well was “care for challenging clients.” Another visiting professional said “In my experience the care service provides a safe environment for my service user. The staff are polite and appear experienced in working with people with an advanced dementing type illness.” Care plans and risk assessments reflected people’s behavioural needs and gave staff strategies to use. Some staff have undertaken training in ‘Dementia and Challenging Behaviour.’ Abbottswood Lodge DS0000015491.V364795.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a clean and comfortable home. EVIDENCE: Abbottswood Lodge provides a comfortable home for people. There is a pleasant garden that can be enjoyed. A scented garden area using herbs and other plants is continuing to be developed. As part of this site visit a partial tour of the premises was undertaken. Issues noted were feedback to the manager. This included pads being left on view in people’s bedrooms, as this does not support maintaining their dignity. Emergency call points were not fitted with cords, where appropriate, that would help people in calling for assistance. Some redecoration has taken place since the previous inspection. Plans are in hand to further improve and refurbish the premises. When this happens people may benefit if issues such as levels of lighting and choice of carpets/flooring are considered, so that their dementia care needs and sensory needs are taken into account. Management and staff spoken with are aware Abbottswood Lodge DS0000015491.V364795.R01.S.doc Version 5.2 Page 19 that more orientation and directional signage may assist in meeting people’s dementia care needs, and are planning to develop this area. On the day of the site visit the home appeared clean and there were no unpleasant odours. On surveys people felt that the home was ‘always’ fresh and clean. A suitable laundry area is available. Staff have received training in infection control, and guidelines and procedures were available to inform their practice. Abbottswood Lodge DS0000015491.V364795.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People can feel confident that they will be looked after by safely recruited and well trained staff. EVIDENCE: People living at Abbottswood Lodge benefit from being cared for by an established management and staff team where there is a very low turnover of staff. People were positive about the staff. One said “It’s lovely here, the staff are very good.” Relative comments included: “Lovely staff, caring manner,” “I can’t fault them at all,” and “Staff are very pleasant and caring towards all the residents.” A visiting professional said “Clients are supported by competent and professional staff who provide a consistently high level of care.” Staffing levels are maintained at three staff during the day, and two awake night staff. Rotas showed that these levels are being maintained. The manager and co-proprietors hours are mostly supernumerary to this. There were no comments made to suggest that staffing is not sufficient. On the day of the site visit staff were available to meet people’s needs at all times. The manager said that staffing would be flexible according to need. Since the previous inspection a number of staff have achieved a National Vocational Qualification (NVQ.) Of fifteen care staff five have achieved NVQ at level three and four at level two. One member of staff has an equivalent qualification. This shows a positive commitment towards staff training. Abbottswood Lodge DS0000015491.V364795.R01.S.doc Version 5.2 Page 21 Only one member of staff has been recruited since the previous inspection. Their file showed that all relevant checks had been completed before the person started work so that people in the home were safeguarded. The member of staff confirmed, “I had to wait a number of weeks until I was able to start work.” The recently recruited member of staff has commenced an induction programme based on Skills for Care standards. It was seen that modules of this such as Control of Infection and Related Items had been commenced. A supervision note said that the member of staff had been ‘welcomed to the home and informed that their induction would take place over a number of weeks.’ The manager said that any new member of staff would be supernumerary for the first week at least. It was advised that a record be kept of people’s basic induction into the home, so that it could be evidenced that fire procedures and basic tasks had been covered. On a survey a member of staff said “I had the whole week for initial induction. Almost everything I needed was covered during this week.” Staff spoken with, the homes training matrix and staff files viewed showed that training is ongoing, and that most staff have completed essential training such as dementia care. Staff were positive about the training and support available. Some comments received were: “Myself and other carers go to regular training courses that are relevant to care, we are also going to be doing long distance training course packages in the home,” “Over the years I have regularly updated my training whether it was new training or updating expired certificates. I have recently completed NVQ level 3 which I found very interesting and enjoyable. I hope to increase and update my knowledge to ensure that I am providing the best quality of care,” and “I do feel I have the right support I am learning new things everyday and my manager is always at hand if I need to ask anything that I don’t know as are lots of different social care books in the home.” Another member of staff recognised the importance of putting knowledge into practice and said, “Courses are being attended. The most important thing is it’s up to staff to always implement what they have been taught, i.e. put into action the knowledge they gained on courses.” Abbottswood Lodge DS0000015491.V364795.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 37, 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People live in a safe and well managed home EVIDENCE: The owner/manager is experienced and well qualified. As well as having nursing qualifications they have also completed their Registered Managers Award, which is a recognised qualification for those managing care homes. Observations during the site visit showed that there is an open culture in the home. Staff gave positive feedback about management. One said, “My manager is always available for advice and support and she regularly discusses our work with us and gives constructive feedback.” Another said “The manager regularly holds staff meetings where all staff get to have their say. We also have regular supervision.” Abbottswood Lodge DS0000015491.V364795.R01.S.doc Version 5.2 Page 23 The providers have strategies in place to monitor the quality of the service. An annual survey is undertaken with questionnaires being sent out to relatives and professionals. It was seen that the results of last years surveys had been sent out to relatives, and that as a result of comments received, menus at the home had been changed. The format for this years survey has been changed to allow for people’s comments, rather than a purely tick box format. Many people living at the home are unable to express their views about the service, but most have family involvement. As observed at the site visit good ongoing relationships between the home and relatives are maintained. Management at the home completed this years AQAA and returned to us on the due date, which followed the site visit. The AQAA was well completed and showed that the manager is aware of where the home can improve and plans to address this. Some people living at Abbottswood Lodge have their personal monies maintained by the home’s management for safekeeping. Those sampled balanced, and good records were maintained. Since the previous inspection CSCI have received only two ‘notifications’ of deaths. The manager was reminded that notifications must be made, and CSCI informed of any deaths, incidents, accidents, admissions to hospital or other occurrences that affect the wellbeing of people living at the home. A random selection of service and maintenance records were sampled and found to be in good order. For example, fire drills, passenger lift and Portable Appliance Electrical Test. A fire service visit took place in March this year. There was one area of non-compliance which management are addressing. The manager is a moving and handling trainer/assessor. At the previous inspection they had let their accreditation lapse. At this inspection it was stated that the qualification had been renewed a month ago, but staff had still not received update training. From the home’s training matrix, staff who have received training in moving and handling, last did so in 2006. Other staff have no training recorded. During the site visit it was noticed that some practices could potentially be improved, for the benefit of residents and staff, by the use of appropriate equipment. Food hygiene is another core area where a number of staff have yet to receive training. The manager said that they are about to address this through a distance learning course. One member of staff does not appear to have received training in any core area. Abbottswood Lodge DS0000015491.V364795.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X 2 2 Abbottswood Lodge DS0000015491.V364795.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No 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 OP18 Regulation 13(6) Requirement So that staff have access to up to date information that will help them to keep people safe, the home’s adult safeguarding policies and procedures must be reviewed so that they provide correct and detailed information. CSCI must be informed of any deaths, or events occurring in the home where the health or wellbeing of people is affected. So that people care cared for safely and staff protected, all staff must be trained in safe moving and handling techniques and be regularly updated in this area. Timescale for action 01/07/08 2. OP37 37 01/07/08 3. OP38 13(5) 14/07/08 Abbottswood Lodge DS0000015491.V364795.R01.S.doc Version 5.2 Page 26 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 OP9 Good Practice Recommendations The storage arrangement for medication should be reviewed, and temperatures in the storage areas monitored, so that medicines are stored correctly and safely. The planed refurbishment of the home should incorporate evaluating the premises from the perspective of people’s dementia care needs. 2. OP19 Abbottswood Lodge DS0000015491.V364795.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Abbottswood Lodge DS0000015491.V364795.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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