Inspection on 18/06/07 for Abigail House

This inspection was carried out on 18th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 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

Abigail House 25/01/06

Abigail House 15/02/05

Abigail House 03/11/04

Abigail House 08/03/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Abigail House 173 West Avenue Westerhope Newcastle Upon Tyne Tyne & Wear NE5 5JH Lead Inspector Alan Baxter Key Unannounced Inspection 09:30 18 and 22nd June 2007 th 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 Abigail House DS0000000431.V338035.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. Abigail House DS0000000431.V338035.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abigail House Address 173 West Avenue Westerhope Newcastle Upon Tyne Tyne & Wear NE5 5JH 0191 286 2468 0191 214 6364 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) Manor Care Home Group Mrs Kath Gordon Care Home 29 Category(ies) of Dementia - over 65 years of age (19), Old age, registration, with number not falling within any other category (10) of places Abigail House DS0000000431.V338035.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th January 2006 Brief Description of the Service: Abigail House is a care home situated in a quiet residential area of Westerhope, Newcastle upon Tyne. The home is close to the village that provides all local amenities. The home is a two-storey building providing 19 places for service users with Dementia Care needs and 10 places for service users requiring 24hour personal care. The home cannot provide nursing care. The home has bedrooms over two floors, only one is en-suite. There is ample lounge and dining room space and the home has a pleasant secure garden area. The weekly fees range from £373 to £400. Abigail House DS0000000431.V338035.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Before the visit: We looked at: • Information we have received since the last visit on 25th January 2006. • How the service dealt with any complaints & concerns since the last visit. • Any changes to how the home is run. • The provider’s view of how well they care for people. • The views of people who use the service & their relatives, staff & other professionals. The Visit: An unannounced visit was made on 18th and 22nd June 2007. During the visit we: • • • • • • Talked with people who use the service, relatives, staff, the manager & visitors. Looked at information about the people who use the service & how well their needs are met, Looked at other records which must be kept, Checked that staff had the knowledge, skills & training to meet the needs of the people they care for, Looked around parts of the building to make sure it was clean, safe & comfortable, Checked what improvements had been made since the last visit. We told the manager what we found. What the service does well: The home makes sure that it can meet all the needs of a new resident before the person is admitted. The home draws up very good care plans to meet those needs, and has them in place before the person comes into the home. There are safe systems for storing and giving medicines. Abigail House DS0000000431.V338035.R01.S.doc Version 5.2 Page 6 Residents’ health needs are taken seriously and properly treated. There is a very good programme of social activities for residents, with trips out and visiting entertainers. Relatives and friends can visit at any reasonable time, and are always made welcome. Any complaints (even minor concerns) are taken seriously and are properly investigated. The home makes every effort to keep its residents safe from abuse. The home has enough staff to meet the residents’ needs. The staff have been very well trained, and all have National Vocational Qualifications, many of them at a higher level than is required. The health and safety of residents and staff are taken seriously. Staff take a pride in their work. Residents spoke very highly of the manager and all her staff. The home is well managed by an experienced, competent and well-qualified manager. What has improved since the last inspection? The home now has a new chef, who has introduced new menus that are nutritious, varied and allow a good deal of choice for the residents. Problems previously noted with the hot water supply have been ironed out. The laundry floor has been replaced with a more hygienic impermeable surface, allowing for easier cleaning. The home now keeps the Criminal Record Bureau (CRB) checks it makes on new staff for inspection by the CSCI. The home is improving the recording of its interviews of new staff members to show that all the necessary questions are being asked. Abigail House DS0000000431.V338035.R01.S.doc Version 5.2 Page 7 Some improvements have been made to the home’s quality assurance systems and outcomes. 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. Abigail House DS0000000431.V338035.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 Abigail House DS0000000431.V338035.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. No resident moves into the home before having a thorough assessment of there needs carried out, and knowing that the can meet those needs. EVIDENCE: Assessments: Study of four residents care records showed that a comprehensive assessment is obtained from each persons care manager or social worker before they are accepted into the home. In addition, the homes manager, Mrs Kath Gordon, carries out her own preadmission assessment to confirm that the home can meet all the needs Abigail House DS0000000431.V338035.R01.S.doc Version 5.2 Page 10 identified. If satisfied that the person can be admitted, Mrs Gordon then carries out a further range of assessments, including an activities of daily living assessment, and assessments of social needs, continence, nutritional needs and risk management. These are carried out very promptly and allow for care plans to be drawn up before the new resident is admitted. This is good practice. Assessments are repeated at least every six months, and more often if required. Abigail House DS0000000431.V338035.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): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Each resident has had his or her health, personal and social care needs clearly set out in detailed care plans. These are put in place before the resident is admitted, to make sure they get all the required care from the outset. Every residents health needs are fully assessed and met using the full range of community-based and specialist health professionals and facilities. There are clear policies and practices in place to make sure that residents are given their medication safely and at the right times, and that medicines are safely stored and recorded. Residents privacy and dignity are respected by all the staff at all times. EVIDENCE: Abigail House DS0000000431.V338035.R01.S.doc Version 5.2 Page 12 Service user plan: Each resident has a care plan drawn up for each need identified in their preadmission assessment. These care plans are holistic and comprehensive and include an assessment of risk in each area identified. They give a detailed description of the problems/needs, have clear and achievable goals, and clearly set out the actions that staff must take to meet those goals. Each care plan is evaluated every month, and updated where necessary. Residents and/or their representatives are asked to sign that their care plans have been fully discussed, explained and understood. Overall, the care plans are highly professional and very informative. The fact that the care plans are drawn up before the person is even admitted to the home is particularly impressive, and very good practice. Health care: All areas of an individuals health care needs are identified in the assessment process described in Standard 3, above. Specific health assessments include continence, mental health and skin care. Each identified need is covered in good detail in a care plan, and regularly evaluated. Care plans are person-centred and sensitive. Detailed records are kept of all visits to or from general practitioners, district nurses, dentists, chiropodists, physiotherapists and other health professionals. There is evidence of appropriate referal to health specialists, clinics, outpatients, and records are kept of admissions to and discharges from hospitals. Medication: The home has clear policies and guidance for staff. Residents are asked to sign to give their permission for senior staff to administer their medicines to them, if they are unable to self-administer (no resident is able to do so, currently). The home uses the monitored doseage system to maximise safety to the residents. The Medicines Administration Record (MAR) has a photograph of each resident at the appropriate section, to help with correct identification and prevent medicines being given to the wrong person. Staff names are listed Abigail House DS0000000431.V338035.R01.S.doc Version 5.2 Page 13 alongside the initials they use in the MAR so that the person giving out the medication is always clearly noted. Where any change is to be made to the prescribed medicines, the doctor is asked to sign this: otherwise, two senior staff will countersign changed entries. All staff have been trained in the safe administration of medicines. There is an annual audit by a qualified Pharmacist., whose most recent report (March 2007) made no recommendations for improvements. All medicines, including Controlled Drugs, are securely stored. Privacy and Dignity: In an in-house quality survey, 17 of the 18 residents who reponded said that they are treated with respect by the manager and her staff. All the residents were engaged in conversation during the inspection. All those who were able to give their opinion said that their privacy and dignity are respected by staff at all times. This was confirmed by several visitors. Observation during the inspection confirmed that staff treat all residents with patience and understanding, and with a genuine affection. Care plans also confirm that the home operates in a way that is residentcentred and respectful, and that residents right to privacy is respected. Abigail House DS0000000431.V338035.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): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home provides an excellent range of social activities and stimulation, both in groups and individually. It meets residents spiritual needs on a regular basis. It is open to new and innovative ways of improving the well-being of its residents. Residents are encouraged to be part of their local community, with unrestricted visiting by relatives and friends, and the use of local shops and facilities. Residents are encouraged to be as independent as possible and to make real choices as to how they spend their day. Their previous life style is maintained as much as possible. Residents are given a very good diet, with nutritious, well-cooked and nicely presented food. There is a good degree of choice and snacks and drinks are available at all times. Special diets are well catered for. Abigail House DS0000000431.V338035.R01.S.doc Version 5.2 Page 15 EVIDENCE: Social Contacts and Activities: The home has a daily activities programme that offers a wide range of activities over a four week period. These include board games, floor games, crafts bingo, arm-chair excercises, singalongs, beetle drives, darts, reminiscence, jigsaws and painting. This programme is lead by the homes activity co-ordinator, who works two hours each weekday morning. She takes a personal interest in each resident, having a chat with each one every day and finding out their interests. She also attends monthly meetings with other activity co-ordinators to share ideas. The home books visiting entertainers about four times each year, and some relatives will also hire entertainment for the home when it is their relatives birthday. There are occasional trips out, with recent examples including a shopping trip to Newcastle, a trip to the coast and a lunch time trip to Harry Ramsdens restaurant. Photographs are taken of many of the homes activities and trips and these are displayed in the home. In addition to the group activities, each resident has had an individual assessment of their personal hobbies and interests darwn up, along with a care plan to meet those needs. Examples seen were highly individualised and gave a good insight into the personality of the resident. There is a monthly service of worship (hymns and prayers) and a monthly communion service in the home. One lady is taken to church weekly by her family. Staff would do this, if required. Recent inovations in this important area of care has been the introduction of doll therapy (which has proved to be very beneficial for a number of residents) and of the SONAS activity. This is a way of providing multi-sensory stimulation through a programme of gentle exercise and massage, relaxing music, singalongs, memory-focussed exercises and personal contributions by the participants. Both these activities are research-based and have been introduced with the support and guidance of a behavioural therapist attached to the Challenging Behaviours Team, based at Newcastle General Hospital. This is excellent practice. Community Contact: Abigail House DS0000000431.V338035.R01.S.doc Version 5.2 Page 16 Visitors confirmed that they are encouraged to come to the home and are always made to feel welcome by the staff. There are no restrictions on visiting. Residents can meet their visitors in private, if they wish. Residents may also choose not to see a visitor, if they do not wish to. Relatives and visitors are given a copy of the homes handbook, are encouraged to join in residents activities, and are offered drinks and meals. Residents are supported to use local shops and facilities. There are links with local churches and schools. Autonomy and Choice: Residents are encouraged to make choices about their daily lives as much as possible. They may choose what to wear, when to get up and go to bed, when to bathe, and what to eat. They may choose whether to be involved in activities. Residents are able to smoke if they wish. For residents suffering from confusion, their previous likes, dislikes and personal habits are assessed through talking with their family and or friends. This is recorded in their care plan, and this allows staff to support each resident in living their life as they always have. There is a choice of menu and mealtimes can be flexible to the needs of individual residents. Residents are encouraged to keep control of their own finances for as long as they are able. Information about Advocacy services is displayed in the home. Residents may leave the building when they wish, unless a risk assessment indicates this would not be safe. For such residents, staff are able to accompany them to local shops or just for a walk. Residents may have a key to their bedroom door. Residents or their relatives are asked their permission for taking their photograph, for being prompted or administered their medicines, and for checks at night by staff. New residents may bring personal possessions with them when they come to the home. Meals: Abigail House DS0000000431.V338035.R01.S.doc Version 5.2 Page 17 A new cook was employed eight months ago, as it was felt that, previously, too many convenience foods were being used. Since then, Mother has nothing but praise for the meals and the Chef, said one relative in a survey. There is a four week menu cycle which offers a choice for each meal (including a cooked breakfast available daily) and is varied and nutritious, with a good range of vegetables. Menus are kept under review and are currently being changed with the input of the residents. Drinks and snacks are available at all times, and are actively promoted. The cook has recently completed a nutrition course and is looking to do the intermediate food hygiene course. In conversation, she was knowlegeable about the residents likes and dislikes, and their nutritional needs. She is able to provide special diets, including soft; weight-gain; diabetic; religious; and low fat diets. Food and fluid charts were seen on the care records of those residents with dietary problems. These were detailed and up-to-date. A meal was taken with the residents. It was hot, tasty and well-presented. The dining tables were pleasantly set. Residents were offered a clear choice between two plated meals to avoid confusion. Staff were quietly efficient, offering discrete and sensitive help where required by residents. Abigail House DS0000000431.V338035.R01.S.doc Version 5.2 Page 18 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): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home takes all concerns and complaints very seriously, and responds quickly and properly to them. Residents are well-protected by the policies and practices of the home, and all staff have been given training in how to prevent abuse or bad practice. EVIDENCE: Complaints: The home has recorded seven complaints in the past year. Two were about friction between individual residents; two were laundry/clothing issues; one was about a change of bedroom; one regarding the need for chiropody, and one was an unfounded allegation of abuse. All were responded to positively and promptly; were recorded in good detail; and were reported onto the appropriate authority, where necessary. The proper remedial actio ns were taken (examples included replacing damaged clothing; making a referal to a behavioural therapist; and drawing up a new care plan). Abigail House DS0000000431.V338035.R01.S.doc Version 5.2 Page 19 Protection: The home has suitable policies and procedures for protecting residents from abuse, and for responding appropriately, should an allegation of abuse be received. There has been a recent example of the home responding speedily and proactively to an allegation of abuse. The home contacted social services and the Commission immediately and co-operated fully with the subsequent investigation. This positive approach has been typical of the homes good practice in recent years. All staff, including new starters, have received Protection of Vulnerable Adults (POVA) training. The home does not practice restraint of residents, and would not admit any person who would need such an intervention. Abigail House DS0000000431.V338035.R01.S.doc Version 5.2 Page 20 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is safe and well-maintained. Residents have the agreed minimum space in their bedrooms. The home is kept in a clean and hygienic condition at all times. EVIDENCE: It was a requirement of the last inspection report that water must be delivered to outlets at close to 43oC. (outstanding requirement from 15.02.05). Abigail House DS0000000431.V338035.R01.S.doc Version 5.2 Page 21 This has been carried out. It had been an occasional problem, only, but this has now been remedied. The home is accessible, safe and well-maintained. There is a programme of routine and renewal of the fabric and decoration of the home. There is an accessible back garden with suitable garden furniture. It is wellused in sunny weather. It was a further requirement of the last inspection report that the laundry flooring must be replaced with an impermeable surface (outstanding requirement from 15.02.05). This has been carried out. Space Requirements: It was a requirement of the last inspection report that the resident of bedroom 21 and her family must be consulted as to whether they wish to have the (currently inadaquate) window area improved by opening up the blocked second bedroom window. After consultation with the resident and family, it was agreed that the work will be carried out when the bedroom is next vacated. Hygiene and Control of Infection: The home is clean, hygienic and free from offensive odours. All staff have completed a distance learning course on infection control in the past 18 months. Disposable gloves and aprons are available to staff at all times. Alcohol gel is available in the entrance to the home and in the kitchen and sluice areas for hand sterilisation. Abigail House DS0000000431.V338035.R01.S.doc Version 5.2 Page 22 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home continues to meet the agreed minimum staffing levels for a home of its size and the dependency levels of its residents. There is also a good range of skills within the staff team, allowing them to meet residents needs. Every member of the care staff has achieved a National Vocational Qualification (NVQ) in care, and most hold an advanced qualification. This means that all the staff have successfully demonstrated their competence to meet residents needs. The home has improved its recruitment policies and practices, and takes great care to appoint safe and suitable workers. The home provides staff with a good range of induction and ongoing training, including all the training required by law. It must, however, draw up an individual training plan for each staff member. EVIDENCE: Staff complement: Abigail House DS0000000431.V338035.R01.S.doc Version 5.2 Page 23 Staffing levels are unchanged, and comply with the agreed numbers. These are six staff (seniors and carers) between 8am and 2pm; five between 2pm and 8pm; and three at night. Domestic cover is provided between 8am and 4pm, and laundry cover between 8am and 3.30pm, seven days per week. The cook works between 7am and 3pm, and her assistant between 10am and 5pm. The manager is supernumerary to the rota. There is a very settled staff group, with little staff turnover. Qualifications: All care staff hold National Vocational Qualification (NVQ) level 2 in care. Of the total of 25 care staff, 17 also hold NVQ level 3, and all the others are currently working towards this qualification. This is very good practice, and reflects well on the company, the manager and the staff group. Recruitment: It was a requirement of the last inspection report that evidence of CRB checks must be held on staff files (outstanding requirement from 15.04.05). This has been carried out. Some 21 CRB forms on file were seen by the inspector, who signed them off for shredding. It was a recommendation of the last inspection report that a written record should be kept of all staff recruitment interviews, to demonstrate that all relevant issues (e.g. gaps in employment history) have been discussed with the applicant. This is in the process of being carried out. It is current practice that an applicants work history is fully checked. Two written work references are always taken up; and evidence of identity is required in the form of a range of documents, including passport and utilities bills. Staff are issued with a statement of terms and conditions of employment, so they know what is expected from them. Abigail House DS0000000431.V338035.R01.S.doc Version 5.2 Page 24 Staff training: The home has in place an induction training programme that meets the National Training Organisation specifications. Induction records show that the process is taken seriously, with most areas seen to be fully completed. All new staff are immediately enrolled on the National Vocational Qualification (NVQ) level 2 in care (this meets the requirement to provide foundation training in the first six months of employment). Mandatory training, in the form of training in first aid, food hygiene, health and safety, moving and handling, and infection control, is given to all staff. Although the general commitment to training is very good, there are no individual staff training and development assessment and profile in place. Abigail House DS0000000431.V338035.R01.S.doc Version 5.2 Page 25 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. At the time of this inspection the home was being managed by a very competent, experienced and well qualified manager. The home has a range of quality assurance systems in place, based on seeking the opinions of residents, and it responds positively to all feedback received. There are good systems in place for looking after residents money, where this has been requested. Accounts are up to date and well-recorded. Staff receive supervision from the manager, but not as often as they should. they do not receive annual appraisal as they should. The health and safety of both the residents and the staff are taken seriously, and safety checks and systems are in place to protect them. Abigail House DS0000000431.V338035.R01.S.doc Version 5.2 Page 26 EVIDENCE: Day-to-Day Operations: The registered manager, Ms Kath Gordon, has extensive experience in caring for the elderly. She holds the National Vocational Qualification (NVQ) level 4 in care and in management, and holds the Registered Manager Award. She provides good leadership and demonstrates sound values. She was working her period of notice at the time of this inspection, having recently taken another job in the care sector. Her successor has yet to be appointed. Quality Assurance: It was a requirement of the last inspection report that an annual audit of the views of residents, their families or representatives, staff and visiting professionals about the running of the home must take place.The results of such audits must be published in the service user guide. This has been carried out. The results of the previous years residents survey have been collated, and showed a good level of satisfaction. 18 responses were received. All 18 said that they are happy with their carers. 17 said that they were able to have a say in their care; felt that their needs are being met; said that they are happy with the management and staff; are treated with respect; are happy with the food; and feel that their rights, confidentiality and equality are promoted by the staff. This years survey has just been sent out. It was agreed to date all suveys to avoid confusion. The most recent survey of professionals views provided very positive responses. All said that their service users are well cared for. None had any concerns or complaints. The last relatives survey also showed generally very positive responses. There was evidence that the manager follows up any area of concern raised in these surveys. Residents meetings take place regularly and are recorded. There is a monthly inspection of the home by its line manager, and these are also minuted. Abigail House DS0000000431.V338035.R01.S.doc Version 5.2 Page 27 Service Users Money: The home holds money at the request of 27 of the 29 residents and/or their families. Clear accounts are kept, and every transaction is signed by two staff. Reciepts are kept and are cross-referenced to the account entries. Accounts are audited weekly by the homes manager. The most recent audit by the company was on 1/06/07. Spot checks of the accounts and monies held for two residents found them to be correct to the penny. Staff Supervision: Study of the records of staff supervision found that it is taking place, but not at the frequency required. This seems to be largely because only the manager is currently conducting supervision, and there is too large a staff team for this to be practical. It is recommended that other senior staff are given training in supervision, and that this responsibility is spread wider. There was no evidence of staff annual appraisal. Safe Working Practices: There is a maintenance programme in place, which includes an annual test of all electrical appliances. The company has its own maintenance team. Maintenance and service agreements are in place and are up to date. Lift inspection reports are on file. The home has an annual inspection by the Water Regulations Officer of Northumbria Water. There is also an annual inspection to check gas safety, and carbon monoxide sensors have been installed around the home. The Tyne & Wear fire and rescue service have approved the homes evacuation plan, and a fire risk assessment is in place. The fire log book shows that there Abigail House DS0000000431.V338035.R01.S.doc Version 5.2 Page 28 is a weekly test of fire alarms and emergency lighting, and a fire drill for staff at least every couple of weeks. The accident book shows that all accidents, even those not resulting in injury, are recorded in good detail. There is a monthly summary and evaluation of accidents, with an individual evaluation for each resident. All staff have had health and safety training. Abigail House DS0000000431.V338035.R01.S.doc Version 5.2 Page 29 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 4 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 4 3 X X X 3 X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X X X 3 2 X 3 Abigail House DS0000000431.V338035.R01.S.doc Version 5.2 Page 30 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 OP30 Regulation 18(1)(c) Requirement All staff must have an individual training and development assessment and profile drawn up. All care staff must receive formal staff supervision at least six times per year. All staff must receive an annual appraisal of their work. Timescale for action 30/09/07 2. OP36 18(2)(a) 30/09/07 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 OP36 Good Practice Recommendations Consideration should be given to increasing the number of senior staff trained to provide staff supervision. Abigail House DS0000000431.V338035.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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 Abigail House DS0000000431.V338035.R01.S.doc Version 5.2 Page 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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