Inspection on 28/06/07 for Abbottswood Lodge.

This inspection was carried out on 28th June 2007.

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

Other inspections for this house

Abbottswood Lodge. 14/07/10

Abbottswood Lodge. 26/05/10

Abbottswood Lodge. 14/04/10

Abbottswood Lodge. 10/06/08

Abbottswood Lodge. 18/08/06

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Abbottswood Lodge Church Lane Swanton Abbott Norwich Norfolk NR10 5DY Lead Inspector Mr Pearson Clarke Unannounced Inspection 28th June 2007 10:30 Abbottswood Lodge DS0000067884.V345164.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Abbottswood Lodge DS0000067884.V345164.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Abbottswood Lodge DS0000067884.V345164.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbottswood Lodge Address Church Lane Swanton Abbott Norwich Norfolk NR10 5DY 01692 538455 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) Abbottswood Lodge Ltd Manager post vacant Care Home 22 Category(ies) of Learning disability (16), Learning disability over registration, with number 65 years of age (5), Physical disability (1) of places Abbottswood Lodge DS0000067884.V345164.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th August 2006 Brief Description of the Service: Abbottswood Lodge is a period residence that has been adapted and extended to provide residential accommodation for up to 22 adults with learning difficulties. The property is in a very rural location outside the small village of Swanton Abbott, south of North Walsham. The majority of places are in single rooms and nine of the rooms are located in a self contained unit in the extension. This has its own lounge and kitchenette. People accommodated within the main house generally have higher care needs. The home in addition has spacious communal accommodation and an activities room. The premises stand in extensive grounds overlooking farmland. Fees are £450. Abbottswood Lodge DS0000067884.V345164.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Care services are judged against outcome groups which assess how well a provider delivers outcomes for people using the service. The key inspection of this service has been carried out by using information from previous inspections, information from the providers ,the residents and their relatives, as well as others who work in or visit the home. This has included a recent unannounced visit to the home and this report gives a brief overview of the service and current judgements for each outcome. What the service does well: What has improved since the last inspection? Since last inspected the majority of the homes radiators have been guarded in order to minimise the risk to residents. Work has begun to introduce a learning disability specific induction and foundation training programme for staff and other training has been updated. Abbottswood Lodge DS0000067884.V345164.R01.S.doc Version 5.2 Page 6 What they could do better: 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 DS0000067884.V345164.R01.S.doc Version 5.2 Page 7 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 Abbottswood Lodge DS0000067884.V345164.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 Quality in this outcome area is poor That the provider needs to ensure that a thorough assessment process is in place in order that prospective residents can be assured that their needs and aspirations can be met by the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The last inspection of the service identified the need to develop a thorough and formal admission assessment process in order that any prospective new residents can be assured that the home will be able to meet their needs. During the last year the service has changed hands and this has had an impact on this and other matters identified as needing attention. During the site visit the inspector talked to the new acting manager and to the responsible individual who is also newly involved. From these discussions and inspection of records it could be seen that there have been no new admissions, but the outgoing registered people had not established a robust assessment process. The new owners of the company are already existing providers and the inspector was told that they are about to introduce their own procedures and processes and that this includes a thorough pre admission assessment . During the site visit the inspector looked at the services statement of purpose/ service user guide and could see that it has not been updated to reflect the changes of ownership and management. Consideration was given to making requirements Abbottswood Lodge DS0000067884.V345164.R01.S.doc Version 5.2 Page 9 in relation to the above issues, however as the timescale since the change of ownership to this inspection is short and given the assurances made at the site visit the inspector is satisfied that these issues will be addressed in the coming months. Abbottswood Lodge DS0000067884.V345164.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Quality in this outcome area is poor That residents capacity for independence and choice is compromised by a care planning system which is not supportive of these goals. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the site visit it was apparent that the service’s care planning system was largely unchanged from that identified as needing improvement at previous inspections. Discussion with the manager and information provided by the home confirmed that staff training in care planning has taken place and there has been some improvement in the level of day to day recording. However the basic format is not person centred , contained little evidence of on going review and did not allow for the setting of goals with the individual concerned. The provider confirmed that they intend to introduce the process that they use elsewhere which was described as a person centred planning system. In so doing they should make sure that the plans are appropriate for meeting the needs of people with a learning disability and such plans should Abbottswood Lodge DS0000067884.V345164.R01.S.doc Version 5.2 Page 11 help shape peoples ability to both make decisions regarding their lifestyles and to exercise independence with appropriate levels of risk. Abbottswood Lodge DS0000067884.V345164.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17 Quality in this outcome area is poor That the service needs to do more to ensure that the needs, wishes and aspirations of all who live there are being met through opportunities for appropriate activity both in the home and the wider community. This judgement has been made using available evidence including a visit to this service. EVIDENCE: It was clear from the site visit that the change of ownership and management has affected potential progress in this area. As such there has been no progress in identifying opportunities for work outside of the home for the service user identified as desiring to do this. This was discussed during the visit and the new management gave assurances that this would be addressed, as will be the need to recruit an activities organiser. There have been some changes to the menus since the above changes and the inspector was told that there was more emphasis being put on fresh produce. Comment received from service users indicated that the majority of people were happy with the food and this is consistent with what was found at the last inspection. Abbottswood Lodge DS0000067884.V345164.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is adequate That the service is working hard to ensure that the health care needs of residents are appropriately met however the provider must ensure that mistakes in the administration of medicines do not compromise this. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information received from the AQAA submitted prior to the inspection indicated that the service has continued to train staff in the care of people with dementia as some residents have needs in this area. Day to day recording seen by the inspector showed that the home helps ensure health care needs are met through the intervention of healthcare professionals. In respect of one service user who has a developing dementia which has led to specific management problems an Occupational Therapy assessment had been sought. The results of this were recommendations that that specialist equipment was provided and the inspector was shown that one item had arrived and the others had been ordered. The services arrangements for storage of medication were seen and sample drug administration records were inspected. The storage seen was secure, however the providers have plans to improve it through the purchase Abbottswood Lodge DS0000067884.V345164.R01.S.doc Version 5.2 Page 14 of a secure drugs trolley. Within the sample records seen there were errors and this was discussed with the provider who intends to audit the system to see if the errors seen are isolated or indicative of a more serious problem . The maintenance of a safe system of medication administration system is essential in homes and as such a requirement is made in respect of this. Abbottswood Lodge DS0000067884.V345164.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good That the services approach to dealing with complaints and the protection of vulnerable adults helps to keep residents safe. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection of the home the commission has received no complaints about the service. During the site visit the inspector was shown complaints records which showed the home has not dealt with any complaints internally. It was noted that there appeared to be more than one record for complaints and as in other, areas the new management might usefully review the existing process to make sure that it is structured in a satisfactory way. Pre inspection surveys received by the commission supported the picture of the home as a caring and kindly service. It was clear from records seen that some staff have received recent adult protection training, however the service manager could not be sure if all staff had been trained in this area. This was discussed on the day and the responsible individual for the home gave assurances that they would be auditing current staff members training and any shortfalls would be met. Abbottswood Lodge DS0000067884.V345164.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is adequate Whilst residents generally benefit from a clean and comfortable home the provider needs to ensure that the environment is safe and suitable for the changing needs of an ageing resident group. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the site visit the inspector found the home to be clean and generally in good order. A number of areas have been redecorated over the last year and some new kitchen equipment has been provided. The management confirmed that the laundry is soon to be refurbished with new commercial machines introduced. Since the last inspection work has been undertaken to guard the majority of radiators in the home. Whilst this is to be welcomed it was apparent that radiators in toilets/bathrooms had not been guarded. Given that these are areas of substantial potential risk and that it was not possible to find any risk assessment process to support their omission from the work done, then the requirement made last time is repeated and must be fully complied Abbottswood Lodge DS0000067884.V345164.R01.S.doc Version 5.2 Page 17 with. As identified during previous visits to the home the needs of an ageing resident group are changing and as such the environment is less suitable in some areas. This is particularly true of the first floor of the main home and the provider needs to ensure that this is kept under review. Abbottswood Lodge DS0000067884.V345164.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and 35 Quality in this outcome area is good That service users benefit from well trained staff who are available in numbers so as to meet the day to day needs of residents. The services employment process helps ensure the protection of those living at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the site visit the inspector discussed the homes employment process with the manager and tracked the employment of a recent member of staff. As such the employment process was judged to continue to be robust, offering protection to those living at the home. Staff training was also discussed and records relating to this were seen. The home exceeds department of health targets for NVQ level 2 or above, qualified staff and staff have recently updated moving and handling and first aid. Since last inspected the service has obtained training materials for induction and foundation training produced by the British Institute of Learning Disabilities. This is line with the requirement made at previous inspection and the inspector was told that this was being used by an in house trainer. One member of staff was spoken to and she confirmed that the recent change of management had not had a negative effect on the home. Staffing levels remain consistent with those found at Abbottswood Lodge DS0000067884.V345164.R01.S.doc Version 5.2 Page 19 previous inspection, with the exception of the employment of extra cleaning hours. Abbottswood Lodge DS0000067884.V345164.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42 Quality in this outcome area is adequate That the arrangements for the management of the home are in transition following the change of ownership. As such areas of management function were not as developed as might normally be the case. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the last year the ownership of the service has changed with the company being bought by existing care home providers. The change of ownership has also led to the retirement of the registered managers both of whom had been in post for a considerable period of time. This inspection took place relatively soon after the change and as such found a service in transition. A new manager has been promoted from within the home and is currently working towards achieving the registered managers award. It is difficult to Abbottswood Lodge DS0000067884.V345164.R01.S.doc Version 5.2 Page 21 make informed judgements about the services management given the above and it was clear that the new owners are still introducing their own processes and procedures. It was however noted by the inspector that the acting manager is currently combining the role with direct caring and it is the inspectors opinion that she needs more time as a manager in order to operate in an effective manner. Sample records seen during the site visit indicate that where the home is helping manage service users monies a full account is being kept. No evidence was available of an updated quality system , however the inspector was told that the new owners would be introducing their own system in the near future. Abbottswood Lodge DS0000067884.V345164.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 2 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 x 2 x LIFESTYLES Standard No Score 11 x 12 2 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 x 2 x x 2 x Abbottswood Lodge DS0000067884.V345164.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 13 Requirement That the provider audit the system of medication management in order to assure that it is robust and safe. Any issues arising from that audit are addressed by the provider. That the service introduce and maintain a more effective care planning system That the service ensure that opportunities for work or day services are available to individuals who wish for them That the provider risk assess the heating system and guard radiators which pose a risk to service users. Timescale for action 31/08/07 2. YA6 15 30/09/07 3. YA12 12 30/09/07 4. YA24 13 30/09/07 Abbottswood Lodge DS0000067884.V345164.R01.S.doc Version 5.2 Page 24 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 YA37 Good Practice Recommendations It is recommended that the manager is able to have sufficient designated management time to fully discharge her management duties. Abbottswood Lodge DS0000067884.V345164.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 DS0000067884.V345164.R01.S.doc Version 5.2 Page 26 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!