Inspection on 24/08/06 for Abingdon

This inspection was carried out on 24th August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Abingdon 03/03/09

Abingdon 19/06/07

Abingdon 14/12/05

Abingdon 19/05/05

Abingdon 29/11/04

Abingdon 27/04/04

Abingdon 27/10/03

Abingdon 27/05/03

Abingdon 20/06/02

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

CARE HOME ADULTS 18-65 Abingdon 48 Alexandra Road Southport Merseyside PR9 9HH Lead Inspector Mr Paul Kenyon Unannounced Inspection 24 August 2006 13:00 Abingdon DS0000005355.V296727.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 Abingdon DS0000005355.V296727.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. Abingdon DS0000005355.V296727.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abingdon Address 48 Alexandra Road Southport Merseyside PR9 9HH 01704 533135 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) Raglin Care Limited Miss Gillian F Trickett Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Abingdon DS0000005355.V296727.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users to include up to 9 LD Date of last inspection Brief Description of the Service: Abingdon is a care home offering a service to nine individuals with a Learning Disability. The home is run by a local company, which provides a number of services in the Merseyside area. The service is managed by Gill Trickett and owned by Raglin Care Ltd. The home is located in a residential area of Southport and is located within easy reach of Southports main shopping centre. It is close to local amenities. The service operated from a converted detached house with facilities spread over three floors. A large garden is located at the back of the house. There are a number of communal rooms and these are generous in size and number given the number of service users living in the home at present. There is a passenger lift available yet the needs of service users at present do not warrant the inclusion of any specialist aids or adaptations at present. Current fees in the home are £1200 a week. Abingdon DS0000005355.V296727.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the main key inspection for Abingdon this inspection year and was unannounced with the home being unaware that the inspection was to take place. The inspection took place during the afternoon and early evening and fieldwork lasted around five hours. A number of important, key National Minimum standards for younger adults were used to assess the quality of support provided by the service. Abingdon provides support for nine adults with learning disabilities. Three of these individuals were case tracked during the inspection. This is a type of assessment of the quality of care for these individuals and looks closely into their needs and how they are met by the service. The three individuals were selected because of the complex needs that they have. Nearly all residents were out during the inspection. The Inspector did have the opportunity to speak with two individuals in detail and to briefly meet others who has plans to go out. What the service does well: The service is good at ensuring that all information about prospective residents needs is obtained before they come to live at Abingdon. In this way residents benefit from having their needs met in the long term and enable staff training to occur in preparation for their admission. The service is good at enabling residents to be involved in their care plans. Residents benefit from having all their needs outlined in a plan that is linked to their needs and alter as needs significantly change. All care plans are reviewed and altered as the needs of individuals change.. The service is good at enabling residents to make decisions about their lives. The service is good at identifying those aspects of the daily lives of residents that may present an element of risk to them and reviewing them when necessary. The service is good at ensuring that residents have meaningful contact with their local community either with staff support or otherwise as their risk Abingdon DS0000005355.V296727.R01.S.doc Version 5.2 Page 6 assessments suggest. The service is good at encouraging those who wish to pursue education and in supporting them to achieve this. The service is good at enabling residents to maintain friendships they have developed or in maintaining contact with their families in accordance with their wishes. The service is good at enabling residents to be involved in aspects of daily living and routines within Abingdon. The service is good at providing residents with a good balanced diet and is good at identifying any changes to the nutritional needs of individuals and support them appropriately. The service is good at providing the information to residents to make complaints about the service and deal with them in a constructive manner. The service is good at ensuring that residents are protected from abuse. The service provides a well-decorated, homelike and pleasant environment, which is clean and free of offensive odours. The service is good at enabling residents to be supported by a well trained staff team who are aware of general training in health and safety but also are provided with training on topics directly linked to the individual needs of residents. Residents benefit from a well-managed service that takes their views about the support they receive into account. What has improved since the last inspection? What they could do better: In addition to the following requirements, some good practice recommendations are made and these are outlined in the main body of this report. Abingdon DS0000005355.V296727.R01.S.doc Version 5.2 Page 7 The service must ensure that all newly recruited staff provide proof of their identities to ensure that residents are fully protected through the recruitment procedure. The service must ensure that all fire detection systems are checked on a regular basis to ensure that the health and safety of residents and all concerned is promoted and protected. 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. Abingdon DS0000005355.V296727.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 Abingdon DS0000005355.V296727.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Prospective residents benefit from a service that takes all their needs into account and ensures that all measures necessary for a smooth transition are in place. EVIDENCE: Quality in this outcome area is good. This judgement has been using available evidence including a visit to the service. Two files were examined for the purpose of this inspection. One related to an individual who had come to live Abingdon since the last inspection and another concerned a person whose move to the home was proposed. In the case of the first individual, assessment information was obtained prior to the person being admitted. A Multi disciplinary team had supplied this information and information reflected the complex needs of the individual. Included in the assessment was a history of the individual, their main needs and a comprehensive risk assessment. Staff had been informed of the needs of the individual in advance and training sessions had been held with the staff team to highlight the main needs of the individual. Another person has been identified to move into Abingdon in the near future. This individual already receives support from another service operated by the organisation that owns Abingdon. All information concerning the individual had been obtained from their existing placement. Abingdon DS0000005355.V296727.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Residents benefit from a service that enables them to agree with the care they are provided, reviews care plans on a regular basis and ensures that significant changes to individuals’ needs are included within these plans of care. Residents can make decisions about their lives. Service users are able to take risks as part of their daily lives with support from the staff team. EVIDENCE: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The care plans of three individuals were examined for the purposes of this inspection. All three people have experienced changes to their support. The first file related to the individual who had been admitted into the home since the last inspection. This noted that the person had agreed with the contents of the plan. Two care plans exist for this person. One is a mainstream plan that seeks to provide support in areas such as independent living skills. Another care plan identifies the main areas of support that the person requires. This is subject to a review every week and this process involves the home and the person’s Social Worker. The second care plan was in the process of being Abingdon DS0000005355.V296727.R01.S.doc Version 5.2 Page 11 amended given an incident that had been experienced with the person over the previous two weeks prior to the inspection. Another care plan related to an individual who has remained in the home for some time yet is considered to have complex needs. As with the first individual, this person has two plans, one for general support and one for specific support needs. The support care plan is reviewed every three months with the other care plan, again being subject to a weekly review. Third care plan was examined given that this person had experienced dramatic changes in their needs since the last inspection. This person has one care plan which outlines all the implications for staff support in light of the changed needs. This is a clear document and again is subject to evaluation and review. Daily records that include additional information for staff members to consider supplement all care plans. This was the case for the third individual who required further daily documents to be completed in relation to his diet and fluid intake. Two residents had discussions with the Inspector. Both confirmed that they were able to make decisions about their lives and considered that the resident meetings held on a regular basis enabled this ‘I feel that they listen to us’ ‘I can decide what I want to do’ The home has no responsibilities as appointee for any resident. All residents have their own bank accounts and two again were able to confirm that they have accounts yet needed staff to support them in gaining access to their monies. Information received prior to the inspection suggested that one person relies on a family member to act as appointee at present. Records suggested that all residents have a keyworker although one newer resident has yet to be involved in this process. It is anticipated that this will be resolved shortly. One resident appeared unclear about the role of her keyworker and suggested that this person had been off for some time. The home does not actively use advocacy services and it is recommended that this person receives some form of advocacy to facilitate the aspirations for her future accommodation that she has. Three risk assessments were examined relating to the three individuals case tracked during this inspection. All individuals have these assessments yet the content of them relate to the specific needs faced by each person. One newly admitted resident has a comprehensive risk assessment that has been devised by a Multi disciplinary team. This information has recently changed following an incident and it is anticipated that this will be incorporated into the home’s risk assessment format in due course. Another person who has remained in the home for some time has a risk assessment, which relates to issues in Abingdon DS0000005355.V296727.R01.S.doc Version 5.2 Page 12 accessing the wider community. This has been reviewed very regularly. A third individual has a risk assessment, which has been altered given the changes in his physical needs. The assessment takes into account the difficulties the person is experiencing with his immediate environment and staff are directed to implement simple measures to ensure that the person is not at risk. An addition element in this person risk assessment has meant that further training has had to be undertaken by staff and this relates to the danger of choking. A speech therapist’s report further reinforces this risk assessment. Abingdon DS0000005355.V296727.R01.S.doc Version 5.2 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13 15, 16 and 17 Residents are able to pursue activities as they wish and are supported to be part of the wider community. Residents are able to have appropriate relationships with the support of the service, benefit from a service that respects their rights and provides a healthy diet in line with their nutritional needs. EVIDENCE: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. During the inspection, only three residents remained in the building during the duration of the visit. All other individuals had either gone out or had returned from a trip out at some point. All residents have an activity plan for each day. This provides an individual plan of activities and can include either trips out into the wider community (either independently or with staff support) or include activities within the home. The Inspector spoke in detail with two residents. Both were able to confirm that they go out on a regular basis and know the Southport area well. They also confirmed that they have bus passes. Other individuals, who were present for part of the inspection had either gone out to local shops, had gone on trips further afield (in one case to Wales) or Abingdon DS0000005355.V296727.R01.S.doc Version 5.2 Page 14 were planning a meal out. One resident stated that the home had recently lost its own transport. This was of some concern to the resident and the Manager later in discussions confirmed the matter. The transport did not form the only means for residents to go out yet it did play a part and as a result it is recommended that steps be taken to acquire alternative transport. No residents have paid employment yet residents have attended a local college. One resident stated that she wish to enrol in the near future to do a Maths and English course. She said that staff would assist with this. Another person confirmed that he helped out at a luncheon club and past inspections confirmed that this has been a longstanding activity. All occupation at present is centred around education or in the acquisition of independent living skills. Two residents were able to confirm that they continued to have links with their families. Records confirmed that this was the case for other individuals. One prospective resident who may come to live in the home in the near future has already had the relationships she has taken into account in the care planning process. Records noted that one person does not wish to receive visits or to maintain contact with one family member. This has been documented with a view to this wish being respected by the staff team. Two care plans noted that steps had been taken to ensure that the health of these individuals were being promoted. One resident provided details of daily routines in some depth. She was able to confirm that she had a key to her room and kept it on her. Another resident confirmed the same to the Inspector. Further testimony suggested that residents are able to rise and go to bed as they wish and that routines were generally flexible. One resident was noted being supported to do his laundry with a member of staff. This was carried out in an informal manner part of an everyday activity for this person. All preferred terms of address are included within care plans. On many occasions staff were observed taking to residents in an informal, friendly and informative manner and did not exclusively interact between themselves. One resident remained during the visit pursuing her own activities and this wish to be alone was respected by the staff team. All residents were observed to have unrestricted access to the building with the exception of others’ individual accommodation. An issue had arisen in respect this between two residents and steps had been taken to ensure that the privacy of one resident was being respected. Apart from activities outside in the wider community, there is an expectation that residents will be involved in household routines. These are outlined within activity plans that are agreed by residents on a weekly basis. Two residents confirmed that they ‘hoovered and polished’ their rooms. Another was observed being supported to do his own laundry. Abingdon DS0000005355.V296727.R01.S.doc Version 5.2 Page 15 Meals are provided from a kitchen that is domestic in scale. A dining room is also available leading from the kitchen. A menu is available although choices are included within this. Daily activities did indicate that one resident was to plan his own meal for that evening. Another resident confirmed that she did not have the confidence to prepare meals. In addition to home meals, residents also have the option to have meals out either individually or in small groups. The nutritional needs of one person have altered since the last inspection. Records suggested that this person needs one to one support when eating and has his own menu. This menu includes softer foods given that there is a risk of choking. The meals taken by this person are recorded, as are fluid charts given that this person is at risk of dehydration. Abingdon DS0000005355.V296727.R01.S.doc Version 5.2 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Residents are provided with the support and assistance they require. Residents benefit from a service that meets their physical and emotional needs. Residents benefit from a safe system of medication. EVIDENCE: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Records indicated that all residents with the exception of one are generally independent with their own personal care yet in some cases, prompting is needed by the staff team supporting them. The needs of one have changed to the extent that more ‘hands on’ personal care is needed and this is reflected in the person’s care plan. One resident was able to confirm that she got dressed, washed and bathed herself with the staff letting her wear what she wanted. No resident’s mobility is such at present that mobility needs are needed. Records indicate that all residents have keyworkers and that involvement from specialist team is required in some cases. A sample of three health care records was viewed. In all care plans, information suggests that staff support is required given that each person is at risk of not attending health care appointments. Records are maintained and these suggested that all residents had received health care support when necessary. For one person, records revealed the extent to which health Abingdon DS0000005355.V296727.R01.S.doc Version 5.2 Page 17 investigations had been done by medical services in order to resolve a medical condition and the same records outlined the degree to which the home had supported this person through this. The needs of most residents at present are such that all, with the exception of one, rely on staff to administer medication. It is considered that it is there is a risk of non-compliance with medication if more people began to selfadminister. One person does self-administer medication and a risk assessment outlining steps to do this is available. Medication is stored in a locked cupboard in a room that is in turn locked when not in use. A monitored dosage system is in place with only senior staff administering medication at present. All administration records were noted to be signed appropriately. All received medications are recorded, as are disposed medications, which in turn are signed by the pharmacy to confirm they have been returned. Abingdon DS0000005355.V296727.R01.S.doc Version 5.2 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Residents have their complaints and concerns listened to. Residents are protected from abuse. EVIDENCE: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Since the last inspection a number of residents have made complaints to the organisation. Evidence was available to suggest that these had been responded to and resolved as much as possible. A complaints procedure is available and includes details of the Commission For Social Care Inspection. Complaints records are maintained. Two residents stated to the Inspector that they would see the Manager if they had any concerns. Since the last inspection, two residents have made allegations of potential abuse although these have not been concerned staff or practices within the home. Records suggested that both had been supported by the home in doing this and allegations were proved as unfounded. The home has its own procedure for reporting allegations and staff have signed this. The Local Authority procedure is available and the reporting of the two allegations suggested that the management team were familiar with the reporting process. Nearly all members of staff have attended abuse awareness training and this was confirmed through certificates present. The Manager considers that this is an important part of staff training given the possibility of future allegations being made as people access the community independently. Information is present for staff in respect of whistle blowing as well as contact details for the Commission For Social Care Inspection. Abingdon DS0000005355.V296727.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Residents live in a clean, home like and comfortable environment. EVIDENCE: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. A tour of the premises noted that the environment continues to be well decorated and home like in appearance. No concerns were identified with the standard of decoration during this visit follow the tour of the building and discussions with residents. There are many communal areas in Abingdon provided for nine residents and therefore the building offers the opportunity for residents to pursue activities on their own if they require as much as possible. The same applies to the garden area, which is easy to access and offers an attractive place for residents to use in finer weather. A refurbishment plan has been devised by the organisation. This takes running repairs and ongoing refurbishment of all parts of the building into account. The continence needs of one person are such that there is now a greater emphasis on hygiene within the building. The environment has been adapted to take this persons’ needs into account with the provision of new flooring in Abingdon DS0000005355.V296727.R01.S.doc Version 5.2 Page 20 his bedroom area that enables the floor to be kept clean and hygienic. No offensive odours were noted in any part of the building during the visit. A laundry is available. This is used by residents either with or without staff support as needed. Industrial appliances are in place and a rota further suggests the role residents are expected to take in domestic tasks. The laundry is separate from food storage and preparation areas. Abingdon DS0000005355.V296727.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34 and 35 Residents are not completely protected through the recruitment process. Residents benefit from a well-trained staff team who are aware of individual as well as general needs. EVIDENCE: Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Two files relating to newer members of staff were viewed. In both cases, the majority of documentation was in place including, application form, police clearance check, two references and medical declaration. No proof of identity was available for these individuals and this is raised as a requirement in t his report. Training records are available for al staff members. Mandatory training had been undertaken or had been identified as future training for some staff. Mandatory training undertaken included: Fire Awareness, First Aid, Food Hygiene, Manual Handling and health and safety. Further documentation included specialist training linked to the needs of residents. This training included Epilepsy, Autism, Self Harm, Communication Difficulties and Choking. The home has access to the organisations training department and a system for nominating staff on course in place. A training plan for 2006 is also available. Abingdon DS0000005355.V296727.R01.S.doc Version 5.2 Page 22 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42 Residents receive support from a well-managed service that listens to their views. The health and safety of residents is not completely promoted. EVIDENCE: Quality in this outcome area is adequate. This judgement is made using available evidence including a visit to the service. The Manager has managed the service for some time and has the necessary experience and qualifications to do the job. The Manager also takes periodic training as evidenced by training certificates. The Manager has a job description outlining her tasks in relation to the registration of the home. The home seeks to ensure quality assurance in a number of ways and this includes the organisation as a whole. A Senior Manager of the organisation inspects the home on a monthly basis and these are sent to the Commission for Social Care Inspection. The last visit was held the week before the inspection and included an action plan to address any outstanding issues. Abingdon DS0000005355.V296727.R01.S.doc Version 5.2 Page 23 Residents have meetings every two months and this provides the opportunity for issues to be raised by residents in respect of their needs or aspirations. This gives residents the chance to air their views on the service. One resident stated that she felt staff listened to her. The staff team demonstrated co-operation throughout the visit and enabled the Inspector to speak with residents in private. No requirements were raised at the last inspection although any requirements in the past have been acted upon. The organisation conducts its own quality assurance exercise and this commences in February each year. The review takes in all users of all its services. The policy outlines that feedback will be made in the following October of each year. It is considered that this timescale is too long and it is recommended that the time between the audit occurring and feedback given is shortened to ensure that urgent issues are acted upon. The audit involves questionnaire sent to residents, relatives and staff. Health and safety systems are in pace and training is provided as outlined in Standard 35 of this report. A health and safety check is made each week and this includes a tour of the building to identify any issues that arise. Accident records show minimal incidents and no pattern emerges as a result of this. Fire records are maintained in the main and show that a recent fire drill was undertaken as well as checks to the fire fighting appliances and emergency lighting systems. Records did not indicate that fire alarms were tested once a week. This is raised as a requirement. In addition to this, a risk assessment for one resident necessitates a smoke detector being placed in his individual accommodation. Checks to this should be weekly but records did not confirm this. This is raised within the same requirement. Other health and safety measures included the provision of a fire risk assessment, general risk assessments, provision of radiator covers and testing of water temperatures. Abingdon DS0000005355.V296727.R01.S.doc Version 5.2 Page 24 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 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 2 X Abingdon DS0000005355.V296727.R01.S.doc Version 5.2 Page 25 NO Are there any outstanding requirements from the last inspection? 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 2 Standard YA34 YA42 Regulation 17(2) Schedule 4 23 Requirement All personnel files must include proof of staff’s identity All fire detection systems must be subject to weekly testing Timescale for action 30/09/06 31/08/06 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. 2. 3. Refer to Standard YA7 YA12 YA39 Good Practice Recommendations Advocacy service should be provided to the residents identified during the inspection The availability of home transport should be examined The organisation should take steps to ensure that the timescale between gaining the views of residents and their families and providing the outcomes to them is not excessive. Abingdon DS0000005355.V296727.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG National Enquiry Line: 0845 015 0120 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. 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