Inspection on 21/05/08 for Abiden Rest Home

This inspection was carried out on 21st May 2008.

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

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

Other inspections for this house

Abiden Rest Home 04/07/07

Abiden Rest Home 09/05/06

Abiden Rest Home 29/11/05

Abiden Rest Home 08/06/05

Abiden Rest Home 28/04/04

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

CARE HOMES FOR OLDER PEOPLE Abiden Rest Home 22/24 Rosehill Road Burnley Lancashire BB11 2JT Lead Inspector Mrs Julie Playfer Unannounced Inspection 21st May 2008 09:00 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 Abiden Rest Home DS0000009469.V359380.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. Abiden Rest Home DS0000009469.V359380.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abiden Rest Home Address 22/24 Rosehill Road Burnley Lancashire BB11 2JT 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) 01282 428603 Mr John Alexander Pinder Not applicable Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (22) of places Abiden Rest Home DS0000009469.V359380.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th July 2007 Brief Description of the Service: Abiden Rest Home is registered with the Commission for Social Care Inspection to provide accommodation and personal care for 22 Older People. The home is situated within easy access of the town centre and public transport routes. The gardens are attractive and have patio areas, which are readily accessed by the residents. Accommodation comprises of 18 single rooms, 8 of which are ensuite and 2 double rooms both ensuite. There is a chair lift to the first floor. Communal space is provided in 3 lounges, 2 of which have a television and the other is used as a quiet room. There is a separate dining room. The home also has two assisted baths and one shower room. At the time of the inspection the scale of charges ranged from £366.00 to £412.00 per week. Additional charges were made for personal newspapers/magazines, and incontinence pads. There were no additional fees payable for privately funded residents. The registered provider made information available to prospective residents by means of a statement of purpose and service users guide. This document was usually given to relatives and/or prospective residents on viewing the home or at the point of assessment. Abiden Rest Home DS0000009469.V359380.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. A key unannounced inspection, which included a visit to the home, was conducted at Abiden Rest Home on 21st May 2008. At the time of the inspection there were 21 people accommodated in the home, plus one additional person who was in hospital. The inspection comprised of spending time with the residents, looking round the home, reading some of the residents’ care records and other documents and discussion with the staff and the registered person. As part of the inspection process we (the commission) used “case tracking” as a means of gathering information. This process allows us to focus on a small group of people living at the home, to assess the quality of the service provided. Prior to the inspection, the acting manager completed an Annual Quality Assurance Assessment known as AQAA, which is a detailed self assessment questionnaire covering all aspects of the management of the home. This provided useful information and evidence for the inspection. Satisfaction questionnaires were sent to the home for distribution to the staff, the residents and their relatives. Three questionnaires were returned from relatives/visitors to the home and one questionnaire was received from a person living in the home. In addition three questionnaires were received from staff. The responses from the questionnaires were collated and used for evidence purposes throughout the inspection process. What the service does well: Current residents were provided with written information about the home, which ensured that people were aware of the services and facilities provided. Prospective residents and their relatives were supported and encouraged to visit the home prior to admission. This provided people with the opportunity to meet other residents and the staff and have a look round the home. The residents were able to exercise choice and control over their lives. The daily routines were flexible and designed to meet the wishes and preferences of the residents. As such the residents could decide when they wished to get up and go to bed. The residents spoken to felt that the staff respected their rights to privacy and personal care was delivered appropriately. Visitors were welcome in the home at any time and residents were supported to maintain good contact with their family and friends. The relatives who completed a questionnaire were satisfied with the quality of care provided, one Abiden Rest Home DS0000009469.V359380.R01.S.doc Version 5.2 Page 6 person commented, “Abiden has created a very home from home atmosphere, both in the physical environment and the friendliness of the staff”. The residents were aware of the complaints procedure and knew who to talk to in the event of a concern. This meant they had the opportunity to resolve any queries at an early stage. Information was available to staff about the protection of vulnerable adults, which included a clear procedure to be used in the event of an alert. The residents were provided with clean comfortable bedrooms. The residents could personalise their rooms, with their own belongings. The sitting and dining areas were decorated in a homely fashion, with a variety of armchairs, footstools, side tables, ornaments and pictures. A good percentage of staff had achieved NVQ level 2 or above. This qualification provided the staff with the necessary knowledge to carry out their role effectively. What has improved since the last inspection? Since the last inspection, the registered person and the acting manager had ensured that residents had not been admitted to the home without a full assessment of their individual needs. This enabled the registered person and prospective residents to determine whether or not their needs could be met and the residents were making the right decision to move into the home. The acting manager had delegated the task of developing and updating the care plans to the team leaders. This initiative was designed to incorporate more information about the residents’ preferred daily living activities and their social and spiritual needs. The registered person had purchased various games, which could be used on a daily basis for individual or group activities. The games could be used both inside and outside the home. The acting manager had devised new supervision and appraisal forms, which incorporated a section on the policies and procedures operational in the home, including the safeguarding procedures. The staff had received training in safeguarding vulnerable adults, which included a test of their knowledge by the use of questionnaires. This meant staff were aware of when incidents needed to be reported and who to refer the incident to. Several improvements had been made to the premises both inside and out. These included the replacement of all windows, doors and fascia boards and the installation a decked area in the back garden. The latter could be used by the residents to sit or play outdoor skittles in fine weather. In addition two new adjustable beds with pressure mattresses had been purchased to improve the comfort and safety of residents with more complex needs. Abiden Rest Home DS0000009469.V359380.R01.S.doc Version 5.2 Page 7 The registered person had produced a business/annual development plan, which set out the planned developments for the service over the forthcoming year. The Commission had been informed about incidents and accidents in the home over the previous year. This was in order to comply with legal requirements set for Care Homes. 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. Abiden Rest Home DS0000009469.V359380.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Abiden Rest Home DS0000009469.V359380.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home had their needs properly assessed and they were provided with appropriate written information to enable them to make an informed choice about where to live. EVIDENCE: Written information was available for the residents in the form of a statement of purpose and service users guide. The guide and the statement of purpose had been amalgamated into one document and was available for reference in each of the bedrooms. The registered person had ensured the guide had been updated in line with any changes in the home. A copy of the inspection report summary was available in the dining room. The guide provided the residents with useful information about the services and facilities offered in the home. The relatives and the resident, who completed a questionnaire, indicated that they had received enough information prior to moving into the home. Abiden Rest Home DS0000009469.V359380.R01.S.doc Version 5.2 Page 10 From the personal files seen it was evident that the residents had been issued with a contract. The contracts had been signed by the residents and/or their representative and included information about the level and payment of fees and the rights of the residents. The contract was easy to read and was presented in a clear format. The ‘case tracking’ process demonstrated that the residents had their needs assessed prior to admission by a social worker and/or the senior staff in the home. Copies of the preadmission assessments were seen on the residents’ files. The assessments covered a range of individual needs and whilst one assessment was not dated, all assessments seen were fully completed. The acting manager confirmed that admissions were not made to the home in the absence of a full needs assessment. This meant the registered person and the acting manager were confident that the staff had the necessary skills and knowledge to meet the assessed needs of the prospective resident. Copies of letters were seen of the residents’ files to indicate the registered person had informed the prospective residents in writing, that having considered the assessment, their needs could be met in the home. The registered person said that prospective residents were encouraged to spend time in the home prior to making the decision to move in. This enabled the resident to meet other residents and staff and experience life in the home. Relatives spoken to during the inspection reported that they had visited the home on behalf of their family member; one person said that she found the atmosphere and the surroundings, “very homely and welcoming”. Following admission, the contract stated that a trial period of four weeks was offered to every resident, so that both parties could make sure the placement was successful and the resident’s individual needs could be met. Intermediate care was not provided at the home. Abiden Rest Home DS0000009469.V359380.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The care plans did not always provide clear information about how best to meet the residents’ healthcare and personal care needs. Appropriate systems were in place to manage medication. EVIDENCE: Three people’s files were looked at in detail as part of the case tracking process. All three files seen contained a care plan, which was based on the person’s significant areas of need. One person’s plan included a personal profile, which provided details about past life experiences. This information was useful for staff to stimulate meaningful conversations with the person. The plans were supported by daily records or personal care, which provided information on changing needs and any recurring difficulties. These records were detailed and the residents’ needs were described in respectful and sensitive terms. Abiden Rest Home DS0000009469.V359380.R01.S.doc Version 5.2 Page 12 The care plans focussed on specific areas of need, such as personal care. This meant that the plans contained limited information and guidance for staff on the residents’ social and spiritual needs and personal preferences for daily living. However, information supplied in the AQAA and discussion during the inspection indicated that the registered person and the acting manager were aware of the shortfalls in the care planning process and had delegated the responsibility for developing and updating the care plans to the team leaders. Whilst discussion with staff indicated the residents were verbally consulted about their care and their decisions were respected, there was no evidence seen to demonstrate the residents had been involved in the care planning process. This meant the residents had limited input into their overall delivery of personal care. All the relatives spoken to during the inspection said they were kept up to date about important issues affecting their family member. From the records seen it was evident the care plans had not always been reviewed on a monthly basis and one person’s plan had not been updated in line with a significant change in condition. It was also noted that not all information from the person’s assessment of needs had been transferred to the care plan. This meant that the staff had limited guidance within the care plan documentation on how best to meet this person’s needs. Healthcare needs were considered during the assessment process and there was written evidence to indicate that the residents accessed NHS services and received specialist support as necessary. Charts were maintained to monitor the residents’ weight, to ensure any fluctuations were noted and acted upon. However, important information about one person’s healthcare condition had not been transferred to the care plan. This meant that staff were not provided with written guidance within the care plan about how to monitor this particular condition, which in turn could have the potential to significantly affect the person’s health. Risk assessments in respect to moving and handling, pressure sores, falls and nutrition had been incorporated into the care plan records. The risk assessments were supported with risk management strategies, to provide staff with guidance on how to manage and reduce any identified risks. However, one person’s moving and handling risk assessment had not been updated following the temporary loss of her mobility. This meant the staff had little information about how to assist this person’s mobility in a safe and consistent manner during this time. The residents spoken to felt the staff respected their rights to privacy and dignity and all made complimentary remarks about the staff, for instance one person said, “The staff are very nice”. The resident, who completed a questionnaire, also commented, “The care and attention given to the residents of Abiden is excellent”. The staff were observed to interact with the residents in a positive manner and they referred to the residents in their preferred term Abiden Rest Home DS0000009469.V359380.R01.S.doc Version 5.2 Page 13 of address. During discussions staff demonstrated an awareness of treating people with respect and considering their dignity when providing personal care. Policies and procedures were in place to cover all aspects of the management of medicines and were available for staff reference in the dining room. The home operated a monitored dosage system of medication, which was dispensed into cassette trays by the local pharmacist. Appropriate records were maintained in respect to the receipt, administration and disposal of medication and all staff designated to administer medication had received accredited training. However, it was noted that the strength of one medication had been entered inaccurately onto the medication administration record (MAR), there was no records pertaining to a prescribed cream for one resident and a homely remedy used by another resident. It was also observed that staff signed the MAR chart prior to the administration of medication. Abiden Rest Home DS0000009469.V359380.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefited from flexible routines and were supported to maintain good contact with their friends and families. The residents enjoyed the meals provided. EVIDENCE: The residents’ preferences in respect of social activities were recorded and considered as part of the assessment process. The registered person and acting manager reported that residents were encouraged and supported to pursue a range of activities and to this end new games and equipment had been purchased. These included giant dominoes, snakes and ladders and draughts. The residents participation in activities had been recorded in their daily care records and included singing and dancing, sitting outside in the garden, listening to music, playing games and watching television. The residents had discussed their choice of recreational activities at a recent residents and relatives meeting. Forthcoming activities were displayed on a white board opposite the kitchen door. Abiden Rest Home DS0000009469.V359380.R01.S.doc Version 5.2 Page 15 Information provided in the AQAA indicated that the residents’ birthdays were celebrated, along with various festivals throughout the year, including Valentine’s Day, Easter, Christmas and Halloween. It was also noted that the registered person intends to consult the residents about trips out of the home. The residents were supported to follow their chosen religion and a representative from the local church visited the residents for communion and prayers every Sunday. One resident attended a local church on a regular basis, which enabled the person to stay in frequent contact with her friends. The routines were flexible and were primarily designed to meet the needs of the residents. The residents spoken to said they had a choice in the times they got up and went to bed. However, one resident was concerned about her bedtime routine. These concerns were discussed with a member of staff, who confirmed the person was offered flexible support in line with her needs and wishes. The staff were observed to seek the residents’ views throughout the inspection and most of the residents spoken to said they felt comfortable to comment on life in the home. The residents had the opportunity to develop and maintain important personal and family relationships. There were no restrictions placed on visiting times and residents were able to receive their guests in the privacy of their own rooms, should they wish to do so. The relatives who completed the questionnaires indicated they were satisfied with the quality of care provided, one person wrote, the home has a “very relaxed atmosphere, affectionate and helpful staff with a genuine caring attitude”. Similar comments were received from relatives seen during the inspection, one person said, “They look after my mother very well, I can’t praise it high enough”. The residents described the meals as “very good” and “really nice”. They also said there was plenty to eat and the food was a good quality. There was a choice of meal each mealtime and residents were asked prior to each meal what choice they wished to make. Breakfast was served throughout the morning to suit the preferences of residents, who wished to have lie in. The meals served on the day inspection looked appetising and were well presented. A range of different drinks was served with the lunchtime meal including various alcoholic beverages, fruit juices and tea and coffee. Whilst most residents were given appropriate assistance to eat their meals, it was noted that one person was not given timely assistance with her choice of cutlery. Drinks and snacks were served throughout the day and at other times on request. Abiden Rest Home DS0000009469.V359380.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents had access to a clear complaints procedure. Appropriate policies and procedures were in place to enable the staff to respond effectively to any allegations or suspicions of abuse. EVIDENCE: The complaints procedure was included in the statement of purpose and service users guide and was also displayed on the wall. The procedure contained the necessary information and included the relevant telephone numbers should a resident wish to raise a concern. Complaint forms were available in the dining room should a resident or their relative wish to make a complaint in writing. The residents spoken to said they could speak to the registered person or the staff if they had a problem. The resident who completed a questionnaire indicated that they were aware of how to make a complaint. The relatives who completed the questionnaires were also aware of the complaints procedure. Information supplied in the AQAA confirmed that the registered person had not received any complaints since the last inspection. Policies and procedures for safeguarding vulnerable adults were available and these provided guidance to staff should they suspect or witness any harmful Abiden Rest Home DS0000009469.V359380.R01.S.doc Version 5.2 Page 17 practice. These issues were incorporated into the induction training and staff received specific tuition as part of their NVQ training. A video was also used for staff training purposes, which tested staff knowledge by the use of an accompanying questionnaire. The completed questionnaires were seen on the staff’s personnel files. Staff had access to a whistle blowing procedure, should they need to report any concerns. Since the last inspection the acting manager had devised new staff supervision and appraisal forms, which incorporated a section on the policies and procedures, including the safeguarding procedures. This was designed to ensure staff were aware of how to respond appropriately in the event of an alert. Abiden Rest Home DS0000009469.V359380.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 23, 24, 25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents were provided with a clean, pleasant and well-maintained environment, which promoted their comfort and independence. EVIDENCE: Abiden Rest Home is a mature property with its own garden. The home is located approximately a mile from Burnley town centre and within easy access of main public transport routes. Accommodation is provided in 18 single rooms, 8 of which have an ensuite facility and 2 double rooms, both of which have an ensuite. Communal space is provided in three living rooms and one dining room. Since the last inspection several improvements had been made to the premises. All the windows, doors and fascias had been replaced throughout the Abiden Rest Home DS0000009469.V359380.R01.S.doc Version 5.2 Page 19 home, a decked area had been installed in the back garden, new hand wash basins had been fitted in two bedrooms and two new adjustable beds with pressure mattresses had been purchased. In addition, some of the residents’ bedrooms had been redecorated and the toilet on the first floor had been replaced and tiled. Established arrangements were in place to report repairs and routine maintenance and the registered person confirmed that appropriate records were maintained of the work completed. A person was employed on a full time basis to carry out the general maintenance. This meant any routine problems with the building were promptly rectified. It was evident on a partial tour of the building that the residents had personalised their rooms with their own belongings and decoration was good throughout. The residents spoken to said they liked their rooms, which they described as comfortable and warm. The bedroom doors had been fitted with appropriate locks and keys had been distributed as appropriate. The locking mechanism allowed staff to gain entry in the event of an emergency call. Radiators were fitted with guards or had a guaranteed low surface temperature. To prevent scalding the boiler was fitted with a central valve and the baths had been fitted with individual preset valves to guarantee water was delivered close to 43°C. A call system with an accessible alarm was placed in every room. The home was clean and odour free at the time of the inspection. The residents spoken to said that a good level of hygiene was maintained at all times. Abiden Rest Home DS0000009469.V359380.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The residents benefited from well trained and competent staff. However, new staff were not sufficiently vetted before commencing work in the home. EVIDENCE: A staff duty roster was drawn up in advance and provided a record of the staffing levels deployed in the home. The roster seen indicated that 3 care staff, plus a manager were on duty 8.00 am to 8.00 pm and two members of staff were on waking watch duty. The registered person and the acting manager were on call out of hours. The staff were split into three teams, each of which was led by a team leader. The teams were well established and staff reported that the teams were working well together. A recruitment and selection procedure was available in the policy and procedure file. The files of two new members of staff were looked at in detail. It was evident both people had completed an application form, provided a full working history and had attended the home for an interview. CRB (Criminal Records Bureau) checks had been obtained. However, it was noted that only one written reference had been received for one person and a reference had not been sought from the person’s current workplace, which involved contact Abiden Rest Home DS0000009469.V359380.R01.S.doc Version 5.2 Page 21 with vulnerable adults. This meant that staff had not been fully checked in accordance with legal requirements, before starting work in the home. Arrangements were in place for all new employees to undertake an in house induction programme and complete a “Skills for Care” induction. The latter provided underpinning knowledge for NVQ level 2. According to information supplied by the registered person, 12 out of 14 members of staff had achieved NVQ level 2 or above, which equated to 86 of the overall staff team. In addition, two members of staff were working towards NVQ level 2, three staff were working towards NVQ level 4 and the acting manager was working towards the Registered Managers Award. All staff who completed a questionnaire confirmed they received training relevant to their role and all commented that they were well supported by the management team with any training needs. Staff attended both internal and external training courses and had at least three paid days training a year. The acting manager reported that staff training records had been entered onto the Lancashire Workforce Development Plan, which is a database on the Internet. This meant that future training needs could be identified and courses arranged as necessary. However, it was noted that not all staff had a staff had a training and development profile. Abiden Rest Home DS0000009469.V359380.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Appropriate systems were in place to monitor the quality of the service provided. However, health and safety practices did not always take full account of the potential risks to the residents. EVIDENCE: The registered person had the overall responsibility for the management of the home and had completed NVQ level 4 in Management and the Registered Manager’s Award. The registered person had also undertaken periodic training, which included safeguarding vulnerable adults, in order to update his knowledge and skills. Abiden Rest Home DS0000009469.V359380.R01.S.doc Version 5.2 Page 23 The management approach was consultative and there were established ways of working to consult the staff and residents on an ongoing basis. Relationships within the home were positive and staff spoke to and about the residents with respect. Since the last inspection the acting manager had devised new staff supervision and appraisals forms and had attended supervision and appraisal training along with two team leaders at Burnley College. The acting manager had plans in place to ensure staff were formally supervised, however, not all staff had received supervision six times during the previous year. The service was awarded an Investors in People Award in 2004, which was due for review in May 2009. Satisfaction questionnaires had been distributed to the residents, their relatives and visiting professional staff in May 2007. The results of the survey had been collated and an action plan drawn up in response to any comment made. The acting manager confirmed that questionnaires were due to be circulated again in the near future. Minutes of a residents and relatives meeting held in March 2008 were seen. The event had been held in the evening and was made into a social occasion for all those who attended. An evaluation was carried out after the meeting to discover what was useful and what could be improved. Since the last inspection, the registered person had produced a business/annual development plan, which set the main objectives for the forthcoming year. This document linked with the AQAA questionnaire submitted to the Commission. All sections of the AQAA were completed and the information gave a clear picture of the current situation within the service and the planned areas for development. At the time of the inspection, the registered person was not managing any money on behalf of the residents. Not all records had been collated and maintained in accordance with the Regulations, for instance the records relating to the care planning processes and the recruitment of new staff. There was a set of health and safety policies and procedures available, which included the safe storage of hazardous substances. Staff had received health and safety training, which included moving and handling, food hygiene, first aid and fire safety. Documentation seen during the inspection demonstrated that the fire and electrical safety systems were serviced at regular intervals. The fire log demonstrated that staff had received instructions about the fire system and fire alarms were tested weekly. Whilst a professional fire risk assessment had been completed, the registered person reported that environmental risk assessments had not been carried out. Further to this, concern was expressed about the staff response to an accident, Abiden Rest Home DS0000009469.V359380.R01.S.doc Version 5.2 Page 24 which occurred during the inspection. The registered person was asked to investigate the occurrence and ensure staff were fully appraised with the health and safety policies and procedures relating to accidents. Since the last inspection the registered person had notified the Commission about incidents and accidents in the home as required by the Regulations. Abiden Rest Home DS0000009469.V359380.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 Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 X 3 3 3 3 STAFFING Standard No Score 27 3 28 4 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 2 2 2 Abiden Rest Home DS0000009469.V359380.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 OP7 Regulation 15 (1) Requirement Following consultation with the residents the care plans must cover all elements of the residents’ health and welfare needs and be regularly updated in line with any changing needs. This is to ensure staff have up to date information about how best to meet the residents needs. The residents’ care plans must include details about specific healthcare conditions wherever appropriate, to ensure staff monitor and respond to any changing condition. Information from the prescription label must be transcribed accurately onto the medication administration record. This is to ensure residents’ receive their medication as prescribed and an accurate record is maintained. Staff must sign the medication administration record following the administration of medication and records must be maintained of all medication held and used on the premises. This is to Abiden Rest Home DS0000009469.V359380.R01.S.doc Version 5.2 Page 27 Timescale for action 01/07/08 2 OP8 15 (1) 01/07/08 3. OP9 13 (2) 21/05/08 4. OP29 5 OP38 ensure accurate records are maintained at all times. 17, 18, 19 All records and checks for new 21/05/08 Schedule members of staff must be 2 (as collated and maintained in line amended) with the Care Homes Regulations 2001. This includes obtaining two written references and references from past employment, which involved contact with vulnerable adults or children. This is to ensure the staff are properly vetted and the residents are fully protected. 18 (1) (c) The registered person must 21/05/08 (i) ensure staff are familiar with and adhere to the procedure to be followed in the event of an accident in the home. This is to ensure the health and safety of the residents. 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 OP8 Good Practice Recommendations Risk assessments and risk management strategies including moving and handling should be updated in line with changing needs. This is to ensure staff have written guidance on how to manage and reduce any identified risks. All residents should be assisted to eat their food as necessary in order to help with their choice of cutlery and ensure they maintain their dignity. Each member of staff should have a training and development plan to ensure their training needs are clearly identified and met. Staff should receive supervision at least six times a year, to ensure they are able to discuss their work performance and identify any future training needs. DS0000009469.V359380.R01.S.doc Version 5.2 Page 28 2. 3. 4. OP15 OP30 OP36 Abiden Rest Home 5 OP38 Environmental risk assessments should be carried out, in order to identify and reduce any risks to the health and safety of residents. Abiden Rest Home DS0000009469.V359380.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ 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 Abiden Rest Home DS0000009469.V359380.R01.S.doc Version 5.2 Page 30 - 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!