Inspection on 03/07/07 for Abbottswood Lodge

This inspection was carried out on 3rd July 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 but made no statutory requirements on the home.

Other inspections for this house

Abbottswood Lodge 14/05/08

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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Abbottswood Lodge 226 Southchurch Road Southend On Sea Essex SS1 2LS Lead Inspector Ann Davey Unannounced Key Inspection 3rd July 2007 10:00 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.V337969.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.V337969.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 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.V337969.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th August 2006 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. Residents’ bedrooms are on two floors, which were accessed by a passenger lift. Residents have a lounge and dining room on the ground floor. The home is owned by Mr & Mrs Peters and managed on a day-to-day basis by Mrs Peters. It is situated in the Southchurch area of Southend on Sea and is therefore in close proximity 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 scale of charges at the home ranges between £470 - £550 per week. Additional charges and costs are incurred by residents relating to hairdressing, chiropody, transport and personal items such as toiletries, newspapers and magazines. Residents are also charged equally when outside entertainers are used in the home. Mrs Peters provided the above information at the time of the inspection. The Home’s Statement of Purpose and Service User’s Guide can be obtained from the home upon request. Abbottswood Lodge DS0000015491.V337969.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key unannounced site inspection which started at 10am and finished at 5.30pm. The last key inspection took place on 15th August 2006. The owners/manager, staff, residents and visitors were spoken with during the course of the visit. In addition the Commission received completed surveys from 6 relatives and 8 residents (some residents surveys had completed on their behalf by immediate family and/or advocate). Comments from these surveys have been incorporated within the report. The day was pleasant and the home was co-operative and helpful. The inspection process was undertaken without any difficulty. A partial tour of the home was made. Care practices were observed and a random selection of records viewed. A notice advising any visitors to the home that an inspection was taking place was displayed in the main entrance hallway. The notice extended an invitation to anyone who may like to speak with the inspector to make themselves known. All matters relating to the outcome of this inspection were discussed with the owners/manager and notes were taken by them. Full opportunity was given for discussion and/or clarification both during and at the end of the inspection. What the service does well: What has improved since the last inspection? The home has been redecorated and refurbished. Some administration and management systems have improved. For example, the information on staff roster and admission assessment documentation. The owner/manager now has her Registered Manager’s Award/NVQ level 4 qualification. The number of staff working very long hours has reduced. The owner (Mr Peters) now works in the home most days and this has further enhanced the workforce. The Statement of Purpose and Service User’s Guide has been reviewed. Abbottswood Lodge DS0000015491.V337969.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 DS0000015491.V337969.R01.S.doc Version 5.2 Page 7 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.V337969.R01.S.doc Version 5.2 Page 8 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): 3 (standard 6 is not applicable in this home) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect to have their care needs assessed by the home to ensure that the proposed placement is suitable. EVIDENCE: One resident has been admitted to the home since the last inspection and these records were assessed. A full assessment was in place and the assessed needs were documented. The wishes and preferences of the resident and family had been sought and recorded. It is the home’s practice to invite any prospective residents to spend some time in the home before any decision about their future is made. On this occasion it was not appropriate for the resident to visit the home, but the inspector spoke with the immediate family who confirmed that they had. The family said that they were very satisfied with admission procedure and the helpfulness of the owners/manager. Abbottswood Lodge DS0000015491.V337969.R01.S.doc Version 5.2 Page 9 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 & 11 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The process of review and amendment to care plans is not sufficiently robust and therefore plans of care and risk assessments did not always reflect assessed or known care needs. Residents cannot be assured that medication practice is sufficient enough to ensure residents safety. EVIDENCE: Four care plan records and other associated care/health documentation were selected and assessed. For example, risk assessment documentation and letters from the hospital. Residents (and where appropriate, family) wishes, choices and preferences are recorded. Care plan and risk assessment documentation was orderly and the home demonstrated that this documentation is reviewed on a regular basis. Documentation evidenced that families are involved in the care planning process and sign to indicate that they support the home in the care provided for their respective facility member. The home is aware that residents’ social, Abbottswood Lodge DS0000015491.V337969.R01.S.doc Version 5.2 Page 10 recreational and any spiritual needs are not recorded on care plans. This was noted at the last inspection. Other required elements of these records had been omitted, were not sufficient in detail or current practice did not promote dignity. For example, bed rail risk assessments were brief and need to be expanded to include full details of how the risk is to be minimised, the behaviour pattern of one resident had not been recorded in the care plan and one plan of care had been placed on a resident’s wardrobe door without evidence that this had been discussed with the respective resident. It was positive to note that residents (and/or those of the family) ‘end of life’ preferences and wishes are sought and sensitively recorded on care records. Records demonstrated that residents are referred to by their preferred or chosen name. Care practices were observed during the day. Staff were attentive to residents needs and were seen to knock on bedroom doors before going in. One resident who was being cared for in bed looked very comfortable. Completed surveys from residents/family indicated that they were satisfied with the care provided. Relatives spoken with during the day were very positive about the care provided by the home. Those residents able to express a view about their care were also positive and said that they were happy in the home. Staff spoken with had a good understanding of residents care needs. Residents were dressed in keeping with their age and gender. The home is currently working on a developing a ‘key worker’ system which will enhance the delivery of care to individual residents. The majority of residents are registered with a local GP group practice. Others are registered with neighbouring practices. The home reported a good working relationship with all health care professionals. The storage of prescribed medication was in good order and medication administration records (MAR records) were orderly. Each resident has an individual PRN (as/when) medication administration protocol in place. It was noted that some dosage and administration instructions concerning prescribed drugs are being handwritten in the MAR records by the home. Any such recording should be ‘double signed’ by the home to prevent any mistakes being made. Unopened prescribed eye drop medication was stored in the fridge as per pharmaceutical instructions, but on opening the bottles they are then stored at room temperature. This was discussed with the owner/manager who said that this was in accordance with local pharmaceutical instructions. It is recommended that this advice be held in writing by the home should there be any further query about current practice. Abbottswood Lodge DS0000015491.V337969.R01.S.doc Version 5.2 Page 11 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 adequate. This judgement has been made using available evidence including a visit to this service. Residents will find that structured and organised activities are limited and they cannot be assured that nutritional records are adequate to demonstrate they are provided with a balanced diet. EVIDENCE: Residents social, recreational and religious needs are not recorded in care plans. This was raised at the last inspection and the home at this inspection said that work has been undertaken on this aspect of care but could not evidence this through documentation. From discussion, this is an area which requires development, as there is no structured programme of events or activities for residents. The owner/manager said that residents like music, ball games and exercises and that one resident likes playing scrabble from time to time. The inspector was told that the last entertainer to come into the home was during 2006. The owner/manager said that residents have to pay for entertainers to come into the home and that this aspect of care is not provided for by the home. Completed surveys sent to the Commission indicated that this aspect of care was viewed as not being so good. Relatives spoken with during the course of the day also confirmed that there was a lack of structured Abbottswood Lodge DS0000015491.V337969.R01.S.doc Version 5.2 Page 12 activity. The owner/manager said that residents ‘don’t want to do anything’ but there was no documentation to support this. The owner said that residents social, recreational and occupational needs were being fully met, but agreed that this could not be evidenced. Throughout the day, residents were in the lounge/dining area. Staff were observed to interact with residents from time to time on a one to one basis, but there was no organised activity/event and for the majority of time residents were left to their own devices. The hairdresser was attending to residents within the dining area, as the home does not have a designated area for this activity. The television was on during the morning, but no residents were watching it. At lunchtime the music was so loud that conversation was difficult, and the owner agreed to turn the volume down. Late morning two residents were seen asleep over the dining room table, staff told the inspector that they like to stay there. During the afternoon, residents were either wandering around the home or asleep in chairs. Two residents had visitors. Only one resident was being ‘occupied’ by a member of staff. There was evidence of good physical care, although there was little evidence to confirm appropriate stimulation or occupation for residents. The home said that all residents have family and or friends who visit from time to time. Approximately ten residents have active family involvement, but only one resident goes out. During the course of the inspection there was a steady stream of visitors to the home. Visitors said that the home always makes them feel welcome, staff are helpful and there is always a welcome cup of tea waiting for them. The home does not have a designated visitors room, so residents have to entertain the guests either in their respective bedrooms or within the main lounge/dining area. At lunchtime, residents were asked if they would like more food or if they had finished their meal before plates were removed. During the afternoon residents were asked if they would like a biscuit. Residents were asked where they would like to sit in the lounge area. Care plan documentation demonstrated that wishes, choices and preferences had been sought from either residents or their families. The home operates a four weekly rotation menu system. The menu for the day was displayed in the dining area. The system demonstrated that residents are offered choice and variety, but the home does not maintain a daily recording system to demonstrate what individual residents chose, had eaten and in what quantity. The reason for maintaining this record was explained to the home. Positive comments were received about food provision within surveys, visitors said that food was presented well and those residents able to express a view said the food was good. One visitor said that since their respective family member had been in the home, the provision of good food had made a Abbottswood Lodge DS0000015491.V337969.R01.S.doc Version 5.2 Page 13 valuable contribution to their improved health and general wellbeing. At lunchtime residents wore clean linen tabards to protect their clothing. Staff sensitively assisted residents who needed help to eat their lunch. Abbottswood Lodge DS0000015491.V337969.R01.S.doc Version 5.2 Page 14 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 adequate. This judgement has been made using available evidence including a visit to this service. Residents can expect to have their complaints taken seriously. A ‘safeguarding residents from harm’ policy is in place, but residents may find that procedures are not followed. EVIDENCE: Completed surveys indicated that relatives know how to make a complaint. Those residents able to voice an view said that they would talk to staff. The complaints procedure was displayed, but the content should be amended to reflect current guidance issued by the Commission. The procedure within the Statement of Purpose and Service User’s Guide should also be amended. The home maintains a complaints record book which demonstrated that complaints are managed appropriately. In the entrance hallway there are leaflets about a local advocacy service. Whilst looking at the entries within the ‘infringement of residents rights’ book it was recorded that one resident had physically assaulted another. Whilst the home had contacted the GP and mental health professionals, although they had not reported the incident as required under the Local Authority ‘safeguarding adults from harm’ policy. The owner/manager said that this had not been done because it was the home’s understanding that only incidents involving staff/resident abuse need to be reported. This understanding is of concern because the owner/manager has attended ‘safeguarding adults from harm’ training courses. The inspector asked the manager to immediately contact the ‘safeguarding adults from harm’ coordinator and report the incident. This was done. The home must review their reporting procedures and Abbottswood Lodge DS0000015491.V337969.R01.S.doc Version 5.2 Page 15 ensure that all staff are knowledgably and competent about ‘safeguarding adults from harm’ procedures and policies. Abbottswood Lodge DS0000015491.V337969.R01.S.doc Version 5.2 Page 16 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. Residents can expect to live in a clean and comfortable environment. EVIDENCE: A partial tour of the home was made. Bedrooms seen were personalised, clean and comfortable. Communal areas were well furnished and decorated. Since the last inspection, all bedrooms have been redecorated, curtains have been replaced and new carpets are being laid. In the lounge, new chairs have been purchased and new blinds at the windows have been fitted. The home has purchased a new lifting hoist, a new commercial washing machine and the kitchen has been completely refitted. The floor covering in two bathrooms and one toilet is to be replaced. There were no unpleasant odours anywhere in the home. The patio/garden area is secure and well maintained. The home is developing a ‘scented flower’ and vegetable area. Visitors said that they home Abbottswood Lodge DS0000015491.V337969.R01.S.doc Version 5.2 Page 17 always looked clean and comfortable and were satisfied with the standard of their respective relatives bedroom. The home is registered for residents with mental health and dementia care needs. In some bedrooms razors had been left on sink shelves, latex gloves had been left in unsupervised areas and the door to the laundry room which is on the 1st floor and contained electrical and cleaning materials was unlocked. The owners said that the razors are of a ‘safety type’ and no resident would go into the laundry area. It was agreed by the owners/manager that by leaving latex gloves in unsupervised areas posed a risk to residents. The home agreed to review all safe working and environmental risk assessments to ensure that adequate risk documentation was in place for the safety and wellbeing of residents and staff. This matter is referenced under the ‘management and administration section of the report. Abbottswood Lodge DS0000015491.V337969.R01.S.doc Version 5.2 Page 18 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 adequate. This judgement has been made using available evidence including a visit to this service. Residents can be expected to be cared for by a developing team of staff, but cannot be confident that staff will have had an sufficient induction or have the skills and training to provide adequate occupational/social activities. EVIDENCE: Staff rosters demonstrate that there is a minimum of 3 care staff on duty during the day and 2 ‘awake’ staff on duty at night. On some shifts, the owner/manger is one of the ‘3’ members of staff, whilst on other shifts the hours are in addition. There was evidence that there are sufficient staff on duty to meet the physical needs of residents although there was no evidence that residents social/recreation needs are assessed and it was not possible to judge whether or not the current staffing complement could meet those needs. The home employs a cook 7 days a week. Mr Peters (owner) now works in the home most days and takes the main responsibility for domestic and maintenance duties. Mr Peter’s input to the day-to-day management of the home has enabled the home to raise environmental standards since the last inspection. It was positive to note that since the last inspection, the owner/manager has reduced her hours in the home significantly and only three staff continue to Abbottswood Lodge DS0000015491.V337969.R01.S.doc Version 5.2 Page 19 work 15-hour shifts i.e. 6pm start then ‘awake’ night shift and finish 9am the following morning. The owner/manager said that on completion of the current recruitment drive, all ‘long’ shifts would cease. Staff confirmed that supervision sessions and team meetings take place. This was supported by documentation. Since the last inspection, the owner/manager said that 7 staff have undertaken dementia and challenging behaviour training, 8 staff have undertaken first aid training, 7 staff have undertaken health & safety training and 3 have undertaken food & basic hygiene training. The difficulty in obtaining an accurate view of staff training was that this information had been handwritten on notepaper, staff records did not record this training and the home’s training matrix was not current. The owner/manager said that 2 members of staff are undertaking NVQ level 2 courses, 3 are undertaking NVQ level 3 courses, 1 member of staff has an NVQ level 3 qualification and arrangements are being made for other staff to attended NVQ level 2 & 3 courses. At the last inspection, it was noted that staff required updates on their moving and handing training, but this had not been undertaken because the owner/manager who is a qualified assessor had allowed her certificate to expire. This was further discussed and the inspector was told that the matter had not been addressed. The home must maintain current records of staff training. The recruitment records of the most recently recruited members of staff were viewed. Records were in good order but the staff induction process was not in line with the current Skills for Care guidance. In addition, there was no provision within the current induction process for identifying future staff training needs. Staff demonstrated a good understanding of individual residents care needs by explaining to the inspector what they do and why they do it and this was reflected within the completed surveys from relatives. Those residents able to express a view were positive about staff. The rapport between staff and residents was observed to be warm, supportive and friendly. Abbottswood Lodge DS0000015491.V337969.R01.S.doc Version 5.2 Page 20 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 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents can expect to live in a home where the management style and processes continue to be developed for the benefit and wellbeing of residents EVIDENCE: The owner/manager has completed the Registered Manager’s Award/NVQ level 4 qualification. At the last inspection, it was felt that the owner/manager needed to concentrate more on the management and administration side of the home as systems were lacking. At this inspection the home was able to demonstrate that some aspects of the administration and management system has improved. For example admission assessments. The owner/manager acknowledges that there are still areas for development e.g. medication practices, nutritional records and activities for residents but said that the home Abbottswood Lodge DS0000015491.V337969.R01.S.doc Version 5.2 Page 21 is committed to raising standards for the wellbeing of residents. From observation and the views of visitors, the provision and delivery of good physical care is evident, the owners/manger demonstrated though discussion and past professional experience a good understanding of mental health, but the day-to-day management processes and systems within the home still require attention and development as evidenced within the report if the home is to meet and maintain regulatory requirements. The home was able to demonstrate that it maintains a positive relationship with all families by being welcoming and communicating well. This ongoing dialogue assists in helping the home to ensure that the best interests of residents are considered. The majority of residents were thought by the home to be unable to express a constructive view of the day-to-day management of the home. The owner/manager said that the home holds resident/relative meetings, but was unable to locate any records to support this. Staff felt that management were approachable and friendly and visitors said that their relationship with the owners/manager was positive. The home has agreed to review all safe working and environmental risk assessments to ensure that risks are recorded, assessed and the management of them appropriately documented. This issue was referenced within the ‘environment’ section of the report. The home keeps small amounts of personal monies for residents. Upon inspection a random selection of records, monies held did not always equate with the stated figure within documentation. Monies were in excess of the recorded amount. The owner/manager said that the home does not maintain current records and works a month behind. This arrangement is not satisfactory as financial records and monies held on behalf of residents must be kept in good order. 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. The home has recently completed a Quality Assurance report that has been given to all relatives. Abbottswood Lodge DS0000015491.V337969.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 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 2 X X 2 Abbottswood Lodge DS0000015491.V337969.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 OP7 Regulation 15 Requirement Every resident must have a detailed plan of care in place. The document must contain adequate risk assessments in relation to bed rails, provide details of assessed needs associated with activities and religious requirements and include care needs associated with individual residents behavioural patterns associated with their mental health. Without adequate documentation, staff may not be aware of assessed or known but not recorded needs or how they should be met. The three previous timescales of 01/09/05, 01/02/06 and 01/09/06 given to meet this requirement has not been achieved. 2 OP9 13 Current medication practices must be reviewed to ensure that they are in line with legislation and guidance for the wellbeing and safety of residents. Details DS0000015491.V337969.R01.S.doc Timescale for action 31/08/07 31/08/07 Abbottswood Lodge Version 5.2 Page 24 of the presenting shortfall are within the report. 3 OP12 OP27 16 A social/recreation/occupational programme must be developed following consultation with residents and families (where appropriate). The programme must be suitable and meaningful taking into account the category of registration and individual needs. This requirement may have implications on current staffing levels, the employment of a suitable qualified and skilled designated member of staff and ensuring that staff have received adequate training to know how to meet assessed needs. 4 OP15 16 The home must maintain a form of record to demonstrate that residents are provided with food and drink which are in adequate qualities, suitable, wholesome, nutritious and varied. A full review of the home’s training in understanding ‘safeguarding adults from harm’ reporting procedures must take place. All staff must be assessed as being competent and able to follow local authority guidance and procedure. The home’s ‘in house’ policy/procedure must be reviewed to ensure compliance with local authority guidance. The incident presented on the day of inspection was immediately reported by the home to the local authority in direct response to the inspector’s request. 31/08/07 30/09/07 5 OP18 13 30/08/07 Abbottswood Lodge DS0000015491.V337969.R01.S.doc Version 5.2 Page 25 At the last inspection (15/08/07) the home was required to review all staff training concerning this matter. 6 OP29 OP30 18 The home must ensure that it can demonstrate that all staff undertake a structured induction training that is in line with current guidance i.e. Skills for Care. The home must maintain an adequate recording system to demonstrate that all staff have received adequate and suitable training relative to their designated roles and responsibilities. 7 OP31 OP38 13,15,16 & 18 Management and administration systems must be in place to demonstrate that all matters relating to the health, care, welfare and safety of residents are monitored, reviewed and addressed for the wellbeing of residents. This is in relation to ensuring care practices are in line with regulation and regulatory records are maintained. For example care plan documentation, risk assessment/environmental risk assessment documentation, nutritional records, ‘safeguarding adults from harm’ procedures, safeguarding residents personal monies and ensuring that residents are provided with appropriate occupation and recreational activity. 30/09/07 31/08/07 Abbottswood Lodge DS0000015491.V337969.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. Refer to Standard Good Practice Recommendations Abbottswood Lodge DS0000015491.V337969.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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.V337969.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. 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!