Inspection on 10/07/07 for Abi House

This inspection was carried out on 10th July 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Abi House 16/02/09

Abi House 28/01/08

Similar services:

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

Insight - Eastchurch

Southfields

Thorndene

Magenta

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

CARE HOME ADULTS 18-65 Abi House 10 St Michaels Road West Worthing West Sussex BN11 4SD Lead Inspector Mrs A Taggart Unannounced Inspection 10th July 2007 03:00 Abi House DS0000069442.V341167.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 Abi House DS0000069442.V341167.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. Abi House DS0000069442.V341167.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abi House Address 10 St Michaels Road West Worthing West Sussex BN11 4SD 01903 212018 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) Independent Lifestyles Limited Michele Anne Waddington Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Abi House DS0000069442.V341167.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection This is the home’s first inspection Brief Description of the Service: Abi House is a care home registered to provide personal care for six service users in the category of Learning Disability. The people currently living in the home all have Acquired Brain Injury. The home is situated in a residential area of Worthing close to the sea front and local shops and amenities. Accommodation is situated over two floors and has a large lounge with a dining area situated near to the kitchen. All bedrooms are single, three rooms have ensuite facilities there are also two additional bathrooms. To the front of the building there is a large courtyard area with a ramp for wheelchair access. The enclosed rear garden has no direct wheelchair access from the house other than by a side entrance. The home does not have a passenger lift. The Registered Provider is Miss Donna Hawes and the Registered Manager is Mrs. Michelle Waddington Current fees are £1,000 to £1,500 per week. Abi House DS0000069442.V341167.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In preparation for the visit an Annual Quality Assurance Assessment (AQAA) was sent to the manager for completion and survey forms were sent to service users, their families and other professionals involved with the home. The AQAA was returned in the given timescales and seven surveys were also returned. Three were from service users, three from families and one from a professional. Information from these documents has been used in this report. The inspector read any relevant documentation and correspondence regarding the home and a planning document was completed. The unannounced inspection was carried out at 3pm and lasted for 3.5 hours. We spent time with the three people currently living in the home both in communal areas and in their private bedrooms and also spent time talking with a visitor to the home. The care plans and all supporting documentation for the three service users were tracked We spoke with the staff on duty, spent time observing staff practice and saw the main meal of the day being prepared and served. Records for the running of the business including incident and accident forms, complaints logs, the fire book and maintenance book were seen. Five staff files that were looked at had all of the required documentation and were in good order. The registered manager Mrs. Waddington was present and received feedback. What the service does well: Abi House provides an attractive and comfortably furnished environment for the people who live there. Two service users say that they are happy with their private bedrooms and are able to see visitors at any time. A service user commented, “its quite nice here, I have had a bit of a job settling in but the staff in the main seem to be good people and know what they are doing”. A comment card from a local G.P. said that there was good communications and good relationships between the home and local surgery. Abi House DS0000069442.V341167.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: In order to provide an effective service and to ensure that the assessed needs of the service users currently living in the home are met, the home must ensure that service users have access relevant professionals in order to address their emotional wellbeing. To ensure that the people in the home are kept safe at all times improvement must be made to the management of medication and clearer instructions put in place to guide the staff team. Appropriate activities must be provided to ensure interest and stimulation for service users and the home must ensure that suitable meals are provided to meet the individual needs of people. In order to ensure that service users are protected from all forms of abuse the staff team must receive training and further support in dealing with the specific needs of the people the home is registered to accommodate. To ensure the safety of service users at all times wedges must not be used to hold back bedroom doors and suitable automatic fire closures should be considered to allow wheelchair users free access in the home. Restrictors must be fitted to upstairs bedroom windows before service users occupy the rooms and aids and adaptations considered for people with a sight loss. To ensure that the people living in the home are treated with dignity and respect and that their confidentiality is respected, the registered manager must review working practices and ensure that the staff team have the guidance and support needed to provide an effective service. Abi House DS0000069442.V341167.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. Abi House DS0000069442.V341167.R01.S.doc Version 5.2 Page 8 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 Abi House DS0000069442.V341167.R01.S.doc Version 5.2 Page 9 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 2 3 and 6 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The home is currently not meeting all of the assessed needs of the people who live there. EVIDENCE: There is comprehensive information available about the services provided in the home and each service user has a copy of the Service User Guide. The ethos of the home is to offer rehabilitation for people in order to enable them to move on to more independent living. Although detailed pre admission assessments have been carried out in conjunction with families and care professionals the home is not currently meeting individual assessed needs in respect of emotional healthcare input, access to the community, environmental issues and staff skills and attitude. Contracts of terms and conditions of residency are kept on each person’s file but have not been agreed and signed by the service users or their representatives. Abi House DS0000069442.V341167.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 9 and 10 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Although care plans are in place and daily records completed there is little evidence that the individual needs of service users are being met. EVIDENCE: Each of the three people currently living in the home has a plan of care in place with a detailed life history; guidelines for individual support needs and risk assessments. Guidelines are in place to inform the staff team of the individual preferences of service users and the manager said that information was being gained all the time in order to ensure that care plans are updated and become “person centred”. Mrs Waddington said that as the service had only been opened for a few months there was still a “settling down” period going on for both the staff Abi House DS0000069442.V341167.R01.S.doc Version 5.2 Page 11 team and service users and said that one person had made a distinct improvement in their health since coming to the home. Although the individual needs and preferences of service users are identified in the care plans, daily records did not show that these were being met and comments made in daily records were often inappropriate and showed a lack of understanding of the needs of the people being supported. One service user’s assessment and care plan states that they became upset and distressed by loud noise and disruptions as these are triggers for a challenging behaviour. This leads the person often isolating themselves in their room as two other service users in the home are recorded to scream and shout when receiving care and when they require attention. Abi House DS0000069442.V341167.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 14 15 16 and 17 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. There is little evidence of activities and outings to offer stimulation and interest being provided and meals do not always meet the individual needs and preferences of service users. EVIDENCE: The Statement of Purpose states that the ethos of the home is to provide people with the skills to move on to more independent living. In the home’s records there was little evidence of any form of stimulation, activities and access to community facilities being provided. People also did not have personal development goals or completed daily activity plans in place. Although care plans and assessments highlight people’s hobbies and interests there was no evidence that people are supported to pursue these. Abi House DS0000069442.V341167.R01.S.doc Version 5.2 Page 13 Daily records show that two people spend long periods of time isolated in their rooms and for one person who has been at the home for a number of weeks only one outside activity was recorded. For another person who has a sight loss, apart from a short, ten minute, orientation exercise carried out daily by the staff, there is no evidence of any activities to motivate and stimulate the person or evidence of access to the community other than to attend medical appointments. This person commented, “Food not bad, don’t do anything all day just sleep and lie down, no going out”. The manager of the home Mrs Waddington said that activities were provided for everyone but there was no written evidence of this. The relative of one service user commented, “My impression is that nothing happens much here; there are two other people who are here but no one for my relative to talk to. I don’t know what stimulation and motivation there is for people. In my relative’s previous home there were all sorts of things going on. There were activities and newspapers to read, you never see one here. There were games and puzzles and quizzes for people to join in. There is none of that here”. The service user said that they spent most of their time, other than at mealtimes lying on their bed and a check of daily records confirmed this. One community activity was recorded in the five weeks the person has lived at the home. Another relative of this person made positive comments about the home and said that they were happy with the care being provided. Another service user said that they did occasionally go out with staff to the local pub and shops but no other activities were recorded other than watching television or using their computer. The home does not have a vehicle to enable access to the wider community or for longer trips out. The manager said that wheelchair accessible taxis and “dial a ride” buses were used but there was no recorded evidence of this. A four weekly menu is in place and the staff on duty said that the people living in the home had helped to compile them. The main meal of the day was seen being prepared and served, was made with fresh ingredients and looked appetising. For one service user who has a sight loss the mealtime caused them to become distressed and agitated. The person’s care plan said that as they had a sight loss, food such as finger food was easier to eat and that the person preferred it. Although a staff member was trying to support the person to eat, they were struggling to cope with eating spaghetti bolognaise; the person was getting it all over themselves and could not manage with a spoon. It was pointed out to the staff that perhaps pasta shapes or a simpler meal would have been easier for the person to deal with. Records of the food people choose are kept but there are no records of monitoring people’s weights in the care plans. Abi House DS0000069442.V341167.R01.S.doc Version 5.2 Page 14 Abi House DS0000069442.V341167.R01.S.doc Version 5.2 Page 15 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 poor This judgement has been made using available evidence including a visit to this service. There are risks to both the service users and the staff team at the home by their being a lack of appropriate emotional support for service users and errors in medication management. EVIDENCE: Care plans contain detailed information regarding people’s healthcare needs and records show that service users have access to a local G.P., district nurses and an occupational therapist and are also supported to attend hospital appointments. The people living in the home have complex physical and emotional needs but at present evidence shows these needs are only being partially met. From observation, talking to service users, a family member and from reading records it is clear that people require input from other professionals such as psychologists or the local community learning disability or mental health teams in order to address their emotional wellbeing. The manager said that a referral was currently being made for one service user but had not yet been considered for the other two people. Abi House DS0000069442.V341167.R01.S.doc Version 5.2 Page 16 From speaking to service users, the staff on duty and looking at records, there is evidence that the staff team, on a regular basis, experience working with a high level of challenging behaviour; there is no evidence that they have received the training and support to enable them to develop the skills and experience to deal with this. During the day some of the staff team were attending challenging behaviour and conflict management training and others had attended earlier in the week. Records show that some staff responses to difficult behaviours are inappropriate and demeaning to the people they are supporting and demonstrate that the staff team do not have an understanding of the complex needs of the service users they are supporting. The staff members on duty were kind and attentive in their dealings with service users but some daily records and behaviour records demonstrate a lack of respect for people by making derogatory remarks regarding difficult situations and detailing inappropriate staff responses. Medication is stored in a locked cupboard on the first floor landing but has been left out loose on shelves instead of being placed in separate containers to identify who it is for. There was also confusing information for the staff team in that a plan for the administration of an invasive medication had been written out for one service user and placed in their personal file and in the medication file but handwritten notes on the Medication Recording Sheet (MAR) gave conflicting instructions. There were also gaps in the signing of the MAR sheets. Abi House DS0000069442.V341167.R01.S.doc Version 5.2 Page 17 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 poor This judgement has been made using available evidence including a visit to this service. Complaints are recorded and acted upon but there are risks to the wellbeing of service users by evidence of inappropriate staff responses and poor understanding of adult safeguarding issues. EVIDENCE: The home has a complaints procedure, a copy of which is contained in the Statement of Purpose and Service User Guide. Two formal complaints have recently been made by local residents concerning noise from the home and alleging poor staff practice. These are logged in the complaints book but no evidence of the investigations or dates for the outcomes have yet been recorded as these are currently being dealt with by the Registered Provider, Miss. Hawes. The staff team receive basic training in the protection of vulnerable adults from abuse as part of their induction process and the manager said that formal POVA training is booked for the future. Records in the home show that some of the staff team do not have an awareness of all forms of abuse and this was evidenced in records kept in the home. On examining daily records and records completed following incidents of challenging behaviour some of the comments written were disrespectful to service users and bordered on being abusive. There was also a lack of respect shown in that during the time that a service user had their relative and the inspector talking to them in their room a hearing monitor was still switched on in the lounge. When asked why it had Abi House DS0000069442.V341167.R01.S.doc Version 5.2 Page 18 not been turned off the manager said that it should have been but the sound had been turned down so that what was being said could not be heard. The staff on duty however, said that they had heard the person playing a musical instrument. Care plans did not record an agreement with people to have monitors in place in their rooms. These issues were brought to the attention of the manager as evidence of the lack of staff competence and respect for service users confidentiality. Mrs. Waddington said that she would deal with them immediately Abi House DS0000069442.V341167.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 25 28 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Although the home is attractive, comfortable and clean it does not currently meet the environmental needs of the people living there and there are risk to people in the event of a fire occurring by doors being wedged open. EVIDENCE: Abi House provides an attractive, comfortable and well-furnished environment and is very clean and hygienic throughout. However although the home is very attractive there are improvements needed to ensure that it fully meets the needs of the people currently living there. There is a large lounge and an open plan kitchen/dining room. One service user said that they did not feel comfortable sitting in the lounge as there was always someone asleep on the sofa and that as they are very tall the seats were too low and uncomfortable. Mrs. Waddington said that she would discuss this with the person concerned. Bedrooms are spacious and well furnished and have been personalised by the Abi House DS0000069442.V341167.R01.S.doc Version 5.2 Page 20 people living in them, they are ensuite and there are also additional bathrooms and toilets on the second floor. Access to the front of the house has recently been improved by the addition of a concrete ramp with handrails but a large uneven front courtyard area makes wheelchair use difficult. Mrs. Waddington said that there was a plan in place to tarmac over this area in the near future. For people who are wheelchair users there is no access to the rear garden other than going out of the house and around the side as in the house there is a narrow archway and a steep step down leading to patio doors with a high lip around. One person who has a sight loss is in a bedroom that is only reached by use of the steep step and there are also no aids and adaptations within the home to support people with a sight loss. In the bedroom of one person, who uses an electric wheelchair, the door was wedged open causing a risk to the person in the event of a fire occurring. The wedge was removed but this then lead to a loss of independence for the person who could not get in and out of their room unaided. A requirement has been made to ensure the safety of service users and to ensure that free access for wheelchair users can be gained to their bedrooms and all areas of the home. In some of the upstairs bedrooms there are double glazed windows that completely open up with a straight drop down to the ground below. This was pointed out to the manager and she said that restrictors would be fitted before the rooms are occupied. There is no lift in place to give access to the second floor. Mrs Waddington said that the home had originally not been adapted for people who are wheelchair users but for people who had good mobility. Advice has been gained from an occupational therapist regarding improvements to the environment and for the use of hoists for one person. Abi House DS0000069442.V341167.R01.S.doc Version 5.2 Page 21 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): 31 32 33 34 and 35 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. The staff team need further training and support in the specific care needs of people with acquired brain injury in order to ensure that they are competent in supporting the diverse needs of the service users currently living in the home. EVIDENCE: Staffing rotas showed that there are three people on duty during the day and one awake and one asleep at night. The manager’s hours are in addition to the rota. During the visit the three staff members on duty were attending training in the lounge of the home and service users were being supported by the manager. Two people were lying on their beds in their rooms. All new staff receive a Learning Disability Award Framework (LDAF) induction and workbooks were in evidence in the home. One staff member said, “This is my third week in the home and I am in my induction period, I have been reading care plans and notes and feel there is good communication at handovers and staff meetings. I am also shadowing other staff”. Abi House DS0000069442.V341167.R01.S.doc Version 5.2 Page 22 A training and development programme is in place for all staff and that includes all mandatory training, NVQ, medication, basic adult protection and an introduction to learning disability. The staff team are dealing with difficult and challenging behaviours on a daily basis, there is however no training in evidence for dealing with mental heath issues or supporting people with acquired brain injury. The manager said that this had been very difficult to access and was now booked for the end of the year. There is also no evidence of people being trained to understand and support people with a sight loss. As previously stated the staff team are currently receiving training and support in dealing with challenging behaviour and with crisis management There is a robust recruitment process in place. Five staff files were seen and all contained the relevant documentation including two references and a Current Criminal Bureau Check. For one person the two references were from work colleagues and it was discussed with the manager that as good practice a reference should be supplied by the previous employer. The staff on duty were kind and attentive in their dealings with people but from discussion and from reading records it is clear that all staff do not have the skills, competence and correct attitude when dealing with the people they support. Please refer to evidence in Standard 18, Abuse. Abi House DS0000069442.V341167.R01.S.doc Version 5.2 Page 23 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 41 and 42. Quality in this outcome area is Adequate This judgement has been made using available evidence including a visit to this service. There are risk to service users and the staff team by lack of effective management of the home. EVIDENCE: The registered manager has many years experience of working with people with a learning disability, holds the NVQ level 4, the Registered Manager’s Award and is an NVQ assessor. The staff on duty were complimentary about Mrs. Waddington and said that she was accessible and supportive. There is an annual quality assurance process in place that is designed to seek the views of service users and other stakeholders but as the service has only been open for three months this has not yet been implemented. Service users meetings are also held and recorded and one Regulation 26 Registered Providers visit report was also seen Abi House DS0000069442.V341167.R01.S.doc Version 5.2 Page 24 The service holds monies on behalf of one service user. This was checked and transactions are recorded, receipts are kept and the cash, which was safely stored, was correct. Staff supervisions are in place and records are kept on file, there are also regular staff meetings. Staff fire training is recorded and regular fire checks undertaken. Although the manager said that the home has only been open for a short time and is in a “settling in” period a number of shortfalls in the management of the service currently being provided were identified. These include failure to ensure that the emotional needs of the people currently being supported are met. That health and safety issues such as ensuring that medication is well managed are not fully implemented, that people are not being protected from risk of all kinds of abuse, the environment does not meet individual needs and that people are not fully protected in the event of a fire occurring. Abi House DS0000069442.V341167.R01.S.doc Version 5.2 Page 25 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 X 2 3 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 X 27 X 28 X 29 2 30 3 STAFFING Standard No Score 31 X 32 2 33 2 34 3 35 1 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 X 2 x LIFESTYLES Standard No Score 11 X 12 2 13 2 14 2 15 3 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 1 1 x 2 x 3 X 2 1 x Abi House DS0000069442.V341167.R01.S.doc Version 5.2 Page 26 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 YA5 Regulation 5 (1) (b) Requirement The registered manager must ensure that each service user has a signed and agreed contract informing them of the terms and conditions of residency in place. The registered manager must provide the people living in the home with a range of activities and community options in order to ensure interest and stimulation In order to address the emotional and mental healthcare needs of service users the registered manager must ensure that referrals are made to the appropriate healthcare professionals In order to safeguard service users at all times, the system of storing and recording of medication must be reviewed and clearer guidelines supplied to the staff team. The registered manager must ensure that service users are protected from risk of all forms abuse at all times, this includes comments regarding them written in the home’s records DS0000069442.V341167.R01.S.doc Timescale for action 10/08/07 2. YA14 16(2) (n) 10/08/07 3. YA19 13 (1) 10/08/07 4. YA20 13 (2) 30/07/07 5. YA23 13 (6) 30/07/07 Abi House Version 5.2 Page 27 6. YA29 23 (1) 7. YA32 19 (5) (b) 8. YA42 23 (1) and also respecting their confidentiality. The registered manager must 30/08/07 ensure that people have safe access to all areas of the home and that aids and adaptations are considered for people with a sight loss. In order that the service users 30/08/07 living in the home are adequately supported, the registered manager must ensure that the staff team have the skills, qualifications and correct attitude to carry out their roles in an effective manner. The registered manager must 30/07/08 ensure the safety and wellbeing of service users at all times by ensuring that fire doors are not wedged open, that suitable automatic closures are fitted so that service user’s independence is maintained and that records in the home are not written in a way that is demeaning to people. 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 Abi House DS0000069442.V341167.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Abi House DS0000069442.V341167.R01.S.doc Version 5.2 Page 29 - 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!