Care Home: Abbey Care Home

What the care home does well The home is fully staffed and there is a stable staff team that residents say are kind and caring. More than half of the staff team have got NVQ qualifications and have had the training needed to help them to provide a good service for the residents. There is a relaxed atmosphere in the home and relatives are welcomed. Families are invited to any celebrations or events organised at the home. Activities are organised daily. Relatives state, "my mother is always well cared for and the staff know mum`s individual needs re: eating, behaviour and sleeping and are always kind, caring and considerate towards her. The home has recently been refurbished and altered to suit the needs of the clients and always looks very clean and tidy including mum`s room. The garden also is kept neat and tidy and if they chose clients can sit outside on sunny days. " Another relative states, "keep the relatives informed at all times and keep the home clean and tidy". What has improved since the last inspection? All the requirements made at the previous inspection have been addressed and are now met. Lounges and corridors have been redecorated. Activities continue to improve, as do the opportunities for residents to go out. Staff receive ongoing training and are knowledgeable and able to meet the needs of the residents. What the care home could do better: The manager and staff team continue to work to provide a good service for the residents and to meet each person`s needs. The requirements in the previous inspection have been met. One requirement and one recommendation have been made from this visit regarding the need for all staff to complete advanced dementia care training and for the proprietor to carry out robust monitoring of the service in order to form an opinion of the standard of care provided in the care home. It was suggested to the manager that she uses the Key Lines of Regulatory Assessment (KLORA) to assist and continue to identify and evidence the excellent quality of the service provided. CARE HOMES FOR OLDER PEOPLE Abbey Care Home Collier Row Road Collier Row Romford RM5 2BH Lead Inspector Harina Morzeria Unannounced Inspection 9:15 2nd July 2008 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 Abbey Care Home DS0000053550.V366221.R02.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. Abbey Care Home DS0000053550.V366221.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbey Care Home Address Collier Row Road Collier Row Romford RM5 2BH 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) 01708 732658 0207 437 1137 Corvan Ltd Ms. Jessie Khan Care Home 20 Category(ies) of Dementia (20) registration, with number of places Abbey Care Home DS0000053550.V366221.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Dementia - Code DE The maximum number of service users who can be accommodated is: 20 6th December 2007 Date of last inspection Brief Description of the Service: Abbey Care Home provides accommodation and support for twenty older people, mostly those who have dementia. This privately owned care home was purpose built and is in a semi-rural location about a mile away from the main shops and transport links of Collier Row. A local bus stops outside the home. All bedrooms are singles, but are quite small, though they have their own en-suite toilets. It has a lift between the ground and first floors. The main communal room is an L-shaped combined lounge and diner. This area has been extended since the last key inspection providing additional space. There is a second small lounge on the first-floor which is used as a quiet area. There are two small bathrooms, both of these have special baths plus a separate shower unit downstairs. The lounges and corridors have been refurbished with new carpets and curtains. All the bedrooms have also been re-carpeted. There is an ongoing refurbishment programme. There is plenty of garden space at the side and rear, and a large front forecourt for parking. The home employs sufficient numbers of experienced and skilled staff to meet the needs of the residents. Personal care is provided on a 24-hour basis, with health needs being met by visiting professionals or by staff accompanying residents to hospital appointments and other healthcare specialists as required. A variety of activities and entertainment are enjoyed by the residents provided by the staff as well as in-house entertainment and outings. A Statement of Purpose is available upon request and a Service Users Guide is given to each prospective resident, which details the service the home can Abbey Care Home DS0000053550.V366221.R02.S.doc Version 5.2 Page 5 provide. The home displays a copy of the Commission for Social Care Inspection report in the foyer and make it available at the request of the service user or their relative/representative. The fees for the home are £480 to £500 per week. Abbey Care Home DS0000053550.V366221.R02.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 Star. This means that people who use the service experience good quality outcomes. This inspection was unannounced and took place over approximately seven hours. The manager, Ms. Jessie Khan and consultant Dr J Khan were present and assisted with the inspection. The inspector looked around the home, spoke to the residents, staff, relatives and observed the lunchtime routines at the home. Care staff were asked about the care that residents receive, and were also observed carrying out their duties. Staff, care and other records were checked. Feedback questionnaires were sent to residents, relatives and staff and a good response was received. Additional information relevant to this inspection has been gained from the Annual Quality Assurance Assessment and Regulation 37 notifications. The Commission has not received any complaints about this service. The inspector spoke to the quality manager for the London Borough of Havering to get feedback about the quality of the service, who stated that they do not have any issues of concern to report. The inspector had a discussion with the manager on the broad spectrum of equality & diversity issues and she was able to demonstrate an understanding of the varied needs of the service users around religion, sexuality, culture, disability and gender. What the service does well: What has improved since the last inspection? Abbey Care Home DS0000053550.V366221.R02.S.doc Version 5.2 Page 7 All the requirements made at the previous inspection have been addressed and are now met. Lounges and corridors have been redecorated. Activities continue to improve, as do the opportunities for residents to go out. Staff receive ongoing training and are knowledgeable and able to meet the needs of the residents. 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. Abbey Care Home DS0000053550.V366221.R02.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 Abbey Care Home DS0000053550.V366221.R02.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 and 5 (standard 6 is not applicable to this service) People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. People who use the service can be assured that their needs will be properly identified and that the service that the home provides is acceptable to them. Information is available in different formats upon request and residents are provided with a written contract or statement of terms and conditions. EVIDENCE: The files of three new residents were viewed and all showed evidence of a comprehensive pre-admission assessment and a statement of terms and conditions or contract. There is a Statement of Purpose & Service Users guide. These are reviewed and updated annually and can be made available in different formats and Abbey Care Home DS0000053550.V366221.R02.S.doc Version 5.2 Page 10 languages upon request. The service user guide informs prospective residents that information is available in different formats upon request. Relatives of the residents spoken to said that they had been given of copy of the guide. Each resident has a contract with the provider and a copy of these were seen in residents’ files. Prospective residents have an individual needs assessment and are given the opportunity to visit the home prior to making a decision to live there. Referrals are made by Social Services department and they provide initial assessment information. This may be from information that they have gathered or from assessments made by hospital staff. Assessments are then carried out by the manager before an individual moves into the home. At this time the prospective residents and/or their relatives are provided with information about the home and encouraged to visit. The assessments cover all of the required areas and include health, mobility, nutrition, religious, cultural and spiritual needs. Examples of this were seen on residents’ files. From this assessment information, an initial basic care plan is drawn up to enable staff to provide appropriate care for an individual when they move into the home. Evidence was seen on new residents’ files that they can visit the home and enter the home for a trial period of stay before deciding to move in permanently. The home does not provide intermediate care. Abbey Care Home DS0000053550.V366221.R02.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, 10,11 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents receive personal care that meets their individual needs and preferences. The healthcare needs of all of the residents are met and clearly recorded in each person’s care plan which is drawn up with the involvement of the resident and/or relatives. Personal support is responsive to the varied and individual needs and preferences of the residents. The medication policies and procedures, and staff training, ensure that all residents are protected through the safe administration of medicines. The staff team are able to meet the needs of residents and support them in a way that they prefer, through gathering detailed information and good care planning arrangements. EVIDENCE: Abbey Care Home DS0000053550.V366221.R02.S.doc Version 5.2 Page 12 The files of three residents were viewed and all had a person centred care plan. There was evidence that residents and/or their family are involved in drawing up the care plans. Reviews take place on a monthly basis, or more frequently if necessary. There was some evidence of life histories and this needs to be developed further. Obviously, the successful development of life stories will need the involvement of relatives because some residents who are living with dementia may not be able to remember some significant events in their lives. All of the residents have care plans, which give details of their needs and how to maintain their independence as far as possible. Individual plans clearly record people’s personal and healthcare needs and detail how they will be delivered. The care plans identify residents’ strengths and capabilities and how their needs should be met. They also contain information about residents’ likes and preferences. For example “prefers to have a shower ”, “likes to rise late in the morning”. Each resident has a nominated key worker. The care plans are used as working tools and are reviewed and updated when a person’s needs change. They therefore contained up to date information to enable staff to meet residents’ current needs. Residents are registered with local GPs. The optician and dentist make regular checks. The district nurse visits as and when required to provide nursing support. Residents’ weight is monitored and dietary needs addressed. Manual handling assessments are in place and reviewed monthly. Aids and equipment are provided to encourage maximum independence for people using services, these are regularly reviewed and are replaced to accommodate changing needs. Specialist advice is sought by the home to ensure the effective use of equipment. Medical information is recorded and the outcome of visits to the doctor or hospital and any follow up action is recorded. Residents are supported to attend doctors and hospital appointments. The manager arranges training on health care topics that are related to the health care needs of the residents to make sure that staff are trained and competent in health care matters relevant to the needs of the people who use the service. The home is registered as a service for people with dementia and staff assist residents appropriately as they have all received basic dementia care training. However, as the service is registered to provide dementia care, all staff should complete advanced dementia training in order to gain a better understanding of the condition and provide an improved level of care to the residents. None of the residents can self medicate and medication is administered by staff that have received medication administration training. There are policies and procedures for the handling and recording of medication. A random sample of Medication Administration Record (MAR) charts were examined and these were Abbey Care Home DS0000053550.V366221.R02.S.doc Version 5.2 Page 13 appropriately completed. The medication records include a photograph of the resident, a medical history and details of any allergies. Medication is appropriately and safely stored in locked cabinets and liquid medicines have the opening dates recorded on them. There are regular times for administering medication. Medication is safely and appropriately administered in a way that meets residents’ individual needs and preferences. The home has a detailed policy, procedure and practice guidance to help staff when caring for residents with degenerative conditions, terminal care and death. All staff receive in-house training and practical advice and have support and opportunities to discuss any areas of anxiety and concern. The manager is in the process of drawing up end of life care plans for each individual. Abbey Care Home DS0000053550.V366221.R02.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 & 15. People using the service experience good quality outcomes in this area. We have made the judgement using a range of evidence including a visit to this service. Residents have the opportunity to join in a range of activities and outings. Visiting times are flexible and visitors are welcomed in the home and residents can keep in contact with friends and relatives. Residents’ views and opinions are important and are used in planning and developing the service. The meals in the home are good and residents have a choice of what to eat. EVIDENCE: Abbey Care Home DS0000053550.V366221.R02.S.doc Version 5.2 Page 15 A variety of activities are provided each day. These include art & craft, bingo, musical entertainment and reminiscence. The care plans seen include information about preferred activities that residents may like to participate in including spiritual and cultural activities. Residents spoken to said that they enjoy the activities. Staff take some of the residents out to the local shops or other activities subject to a risk assessment. One resident ran a riding school and staff have taken her to the local community farm to see horses which she has enjoyed greatly. They also go to Fairlop Waters, theatre outings, local riding school as well as pub lunches. There are photographs of the various activities and outings the residents have enjoyed over the year. The manager hopes to display these in the hallway. A hairdresser visits once per week and ensures that the ladies have their hair done and the gentlemen have their haircuts. The Roman Catholic priest comes to the home every month to give Holy Communion and hold prayers, and residents participate if they wish. A catholic service is conducted by a priest from St Vincent de Paul church. Hymns are sung from large print hymn sheets and this activity is particularly valued by an Italian resident accomodated at the home. Therefore residents spiritual needs are met. Visitors are welcome at any reasonable time. A relative said “ we visit regularly and you can come when you want to.” Another relative commented “if I phone the carers bring mum to the phone”. The AQAA states that residents meetings are held and they talk about what they like, any complaints and where they to go for outings as well as menus. They put forward ideas and staff see what the can do. Residents’ opinions are sought and acted upon. Residents are encouraged to be as independent as possible and to be involved in choices about the home and about their lives. Appropriate activities and stimulation are provided for people with dementia such as board games, reminiscense, photograph albums and music. However, more could be done to develop further relevant activities for people with dementia. One of the residents is bilingual and speaks Italian. There are two staff who can communicate with her in order to be able to understand and meet her needs. There is a list of popular Italian words for staff to use with her. Her family have been encouraged to bring in Italian music tapes so she can listen to music she enjoys. Residents are offered a choice of meals. Special diets are catered for. Meals are served in the dining area and drinks and snacks are available. The night staff make a cup of tea or a drink for any residents who have difficulty sleeping during the night. They all said they enjoy their food. Assistance and encouragement was given to residents who needed help. Abbey Care Home DS0000053550.V366221.R02.S.doc Version 5.2 Page 16 Abbey Care Home DS0000053550.V366221.R02.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. People using the service experience good quality outcomes in this area. We have made the judgement using a range of evidence including a visit to this service. There is a user-friendly complaints procedure that is followed in the event of any complaints being made so that people who use the service are able to express their concerns and dissatisfactions. People who use the service are protected by staff who have received safeguarding adults training to ensure that they are clear about what constitutes abuse and what to do if abuse is seen or suspected. EVIDENCE: There is a complaints procedure and this is displayed in the home. Complaints are recorded and dealt with by the manager and the staff team. Residents and relatives are encouraged to voice any problems so that they can be sorted out as soon as possible. Staff are reminded to record any complaints so that they can be appropriately dealt with and evidence of this was seen in the complaints book. Feedback from relatives states that any concerns raised are dealt with immediately by the manager or the staff team. Abbey Care Home DS0000053550.V366221.R02.S.doc Version 5.2 Page 18 The manager has reviewed the home’s safeguarding policy and procedure which clearly tells staff the actions to take in the event of abuse/suspected abuse being discovered. All staff working within the home are now fully trained in safeguarding adults and know how to respond in the event of an incident being reported. Staff spoken to were aware of the issues surrounding safeguarding adults and aware of their responsibility to residents. Staff, residents and relatives feel able to raise any concerns that they might have. There is a clear system for staff to report concerns about colleagues and managers which ensures that concerns are investigated in line with local policies and procedures. A safeguarding incident did occur at the home in December 2007 which was fully investigated by a manager in the assessment and care management team, London Borough of Barking and Dagenham following the safeguarding adults protocol. As a result of this incident all placements in the home were reviewed by the relevant placing authorities; Barking and Dagenham, Havering and Tower Hamlets. A requirement made at the last key inspection for all staff to complete up to date safeguarding training is now met. There have been no safeguarding issues reported to the CSCI inspector since the last inspection. The manager stated that they do not handle any finances on the residents’ behalf. All staff understand what restraint is and alternatives to its use in any form are always looked for. Equipment which may be used to restrain individuals such as bedrails, keypads recliner chairs and wheelchair belts are only used when absolutely necessary with the home promoting independence and choice as much as possible. Abbey Care Home DS0000053550.V366221.R02.S.doc Version 5.2 Page 19 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, 22, 23, 24, 25 & 26. People using the service experience good quality outcomes in this area. We have made the judgement using a range of evidence including a visit to this service. The residents live in a clean and comfortable home that has suitable aids and adaptations for their needs. The staff team continue to work to improve the environment and to make it as homely as possible. EVIDENCE: Abbey Care Home DS0000053550.V366221.R02.S.doc Version 5.2 Page 20 The home is in Romford on a main bus route. The home is accessible to wheelchair users. On the ground floor there is a lounge/dining area which has been extended since the last inspection and bedrooms are on both floors. New chairs have been purchased for the lounges and the curtains have been changed in these areas which gives the home a fresh and updated look. There is a lift to the first floor. Adapted bathing and toilet facilities are available to meet the residents’ needs. Hoists, slings, grab rails support frames and walking frames are available for residents that need these. Therefore, the equipment needed to meet the residents’ specialist needs is available in the home. The home is appropriately decorated and furnished throughout. Residents are encouraged to bring some of their own furniture and personal possessions with them. The AQAA form returned states that bedrooms and both lounges have been re- carpeted and decorated, all bedrooms have been re-carpeted. A new shower unit has been fitted. A staff/visitor toilet has been installed. New laundry equipment. Lounge area and dining area has been extended by relocating the office. New plants and pots in the front of the house. Appropriate signage is used in the home, for example, pictorial signage on toilets and bathrooms, as well as photographs of individuals on the doors to help them identify their own room. There is a large surrounding garden at the rear of the home and this has a patio area and tables and chairs. It is spacious and accessible. At the time of the inspection the home was clean and free from offensive odours. There is an infection control policy and advice is sought from external specialists if the need arises. All staff have received infection control training and the manager aims to raise staff awareness of this issue further in the coming year. Abbey Care Home DS0000053550.V366221.R02.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. People using the service experience good quality outcomes in this area. We have made the judgement using a range of evidence including a visit to this service. Residents are supported and protected by the homes recruitment practice. Staffing levels are appropriate to support the needs of people who use the service. Staff receive the necessary training, supervision and support in order to meet residents’ current needs and provide a good service for them. Residents are supported by a staff team that know them well and who are committed to providing a good quality service. EVIDENCE: At the time of the visit there were twenty residents living at the home. There are three shifts for staffing the home and the usual staffing is three carers on the day shifts. At night there are two waking night carers. Domestics and kitchen staff support the care staff. There is generally a stable staff team and agency staff have not been used in the recent past. Hence, the home is fully staffed and any additional shifts are usually covered by the staff team. Abbey Care Home DS0000053550.V366221.R02.S.doc Version 5.2 Page 22 Therefore, residents receive a consistent service from a staff group that are aware of their needs and how to meet them and residents get continuity in their care. The staffing arrangements are sufficient and flexible to meet the changing needs of residents. The views of residents who contributed to the inspection was that the staff were available to attend to them and meet their needs. One resident said “staff are always around if you need them”. From observation the staff showed a caring and helpful attitude towards the residents. A relative’s feedback says, “the staff do a wonderful job.” In addition to short courses the staff team have also shown a commitment to achieving their National Vocational Qualifications. More than fifty percent of staff have obtained NVQ Level 2 & 3 qualifications. The home has internal developmental training as well as formal training for staff as part of an ongoing training plan. The training records checked of three members of staff confirmed that they have received training in manual handling, fire safety, infection control, safeguarding adults, oral care, medication and first aid. Hence, staff are receiving the necessary training to provide an appropriate and safe service to meet the needs of the residents and future training needs have been identified. However, although the staff have done basic dementia awareness training they need to undertake further detailed dementia training in order to enhance their knowledge and skill base. The AQAA states that two senior staff have almost completed RGN qualifications at level 4. Also, four staff members have just completed Level 3 NVQ in Direct Care. Staff records seen and feedback from staff confirms that they receive the right support from the manager to meet the different needs of the people who use the service. As the home did not have a manager in post for sometime, staff did not receive regular supervision, however the current registered manager has begun the process and staff records checked show that the supervision process has begun for all staff and an annual supervision plan is in place. Staff have job descriptions and are clear as to their individual role in the home. Staff files checked evidence that the home has a thorough and appropriate recruitment procedure. There are application forms, interviews and the appropriate references and checks are made. A random sample of staff records were checked during the inspection and were found to contain the required information. Abbey Care Home DS0000053550.V366221.R02.S.doc Version 5.2 Page 23 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, 37 & 38. People using the service experience good quality outcomes in this area. We have made the judgement using a range of evidence including a visit to this service. The home is well managed and provides a safe environment for the residents. The manager and the staff team work well together and receive appropriate support to make sure that residents are safe and secure whilst living at Abbey Care Home. The manager sets an example of good practice to her team and is keen to continue to develop the service at Abbey Care Home for the benefit of the people who use the service. EVIDENCE: Abbey Care Home DS0000053550.V366221.R02.S.doc Version 5.2 Page 24 At the time of writing this report the manager was registered as a “Fit Person” by the Commission’s registration team. She has worked in the home for six months and has experience of working with older people. She holds an RGN qualification and has completed her Registered Manager’s Award. The manager undertakes regular training and understands and values opportunities for continuing professional development. Therefore, the registered manager is competent to run the home and meets its stated aims and objectives. The atmosphere in the home is relaxed and friendly and there is a stable staff team. The manager communicates a clear sense of direction, is able to evidence a sound understanding and application of best practice operational systems particularly in relation to continuous improvement, customer satisfaction and quality assurance. Equality and diversity, human rights and person centred thinking are given priority by the manager aiming to continuously improve the service in order to meet the residents’ individual needs. The owner carries out monthly monitoring visits to assess how effectively the home is operating to meet its stated aims and objectives, and reports are written. However, these are brief and do not indicate the action to be taken when deficiencies are identified. Copies of these reports were available in the home. A recommendation is made that the owner carries out his function robustly and thoroughly in order to asses whether the home operates within its stated aims and objectives. Residents are asked for their feedback about the service and improvements are made where gaps are identified. The manager does not handle residents’ finances and any expenses incurred by the residents are invoiced directly to their families or appointees. People are supported to manage their own money where possible. Record keeping is of a good standard. Records are kept securely and staff are aware of the requirements of the Data Protection Act. Residents know they can access their records at any time. The AQAA contains clear, relevant information that is supported by appropriate evidence. The manager recognises the areas that they still need to improve and has detailed ways in which they are planning to do this. The home has a range of policies and procedures to promote and protect residents’ and employees’ health and safety. The manager is proactive with regards to health and safety to ensure that any potential risks are minimised as far as possible. Health and safety awareness issues are cascaded to staff to raise their awareness. Regular health and safety checks are carried out by appropriate professionals. The manager is aware that it is her responsibility to carry out all of the necessary health and safety checks and provide a safe environment for the residents and staff at all times. Abbey Care Home DS0000053550.V366221.R02.S.doc Version 5.2 Page 25 Staff meetings have been taking place regularly, providing staff with the opportunity to discuss problems and to be involved in the development of the service. Staff meetings have an agenda and are minuted. Staff spoken to said that there is very good communication and teamwork in the home. Training and development needs are identified as part of supervision. There are clear lines of accountability in the home. Appropriate insurance cover is in place. Abbey Care Home DS0000053550.V366221.R02.S.doc Version 5.2 Page 26 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 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X X X 3 3 Abbey Care Home DS0000053550.V366221.R02.S.doc Version 5.2 Page 27 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 Requirement All staff must receive training in advanced dementia care. Timescale for action 30/09/08 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 OP32 Good Practice Recommendations The registered person to carry out his function (visits required to be carried out under Regulation 26) more robustly and thoroughly, in order to assess whether the home operates with in its stated aims and objectives and form an opinion of the standard of care provided in the care home. Abbey Care Home DS0000053550.V366221.R02.S.doc Version 5.2 Page 28 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Abbey Care Home DS0000053550.V366221.R02.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!