Care Home: Abbeycroft

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What the care home does well The service plans how people move to the house and makes sure they have the right information and chances to visit. People have an assessment of their needs so they know the service is the right one for them. People have a detailed support plan and are fully involved in all aspects of their support. The service respects people`s confidentiality and people are able to take risks in their daily lives. The service supports people to lead fulfilling daily lives with leisure time and domestic tasks as well as chances for personal development. Meals are varied and people are involved in preparing them. People`s health and support needs are met by the service with involvement of outside professionals as needed. Their medication is managed in a safe way. People are kept safe by the procedures at the service. Staff are recruited safely and have the right skills to meet people`s needs. The house is modern and clean and people can personalise their rooms. The manager makes sure the house is safe and runs the service well. What has improved since the last inspection? This is a new service and this is its first key inspection. What the care home could do better: As people move to the service managers and staff should consider how people`s support can be made personal to them. For example by putting support plans into formats people can use, considering how people can contribute to their own plans, and by considering how people can be supported to take control of their health and support needs as far as they are able to. Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Abbeycroft 16 Crabbs Cross Lane Crabbs Cross Redditch Worcestershire B97 5LD     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Emily White     Date: 0 6 0 2 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Adults (18-65 years) Page 2 of 25 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 25 Information about the care home Name of care home: Address: Abbeycroft 16 Crabbs Cross Lane Crabbs Cross Redditch Worcestershire B97 5LD 01527540403 01527540606 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Edge View Homes Ltd care home 6 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability mental disorder, excluding learning disability or dementia Additional conditions: The maximum number of service users to be accommodated is 6. The registered person may provide the following category of service only: Care Home Only To service users of the following gender: Female Whose primary care needs on admission to the home are within the following categories: Learning Disability (LD) 6 Mental Disorder (MD0 6 Date of last inspection Brief description of the care home Abbeycroft is situated in a quiet residential area of Redditch, close to local shops and other amenities. It is a newly refurbished purpose built house which provides accomodation for six women with a learning disability and associated mental health 6 6 Over 65 0 0 Care Homes for Adults (18-65 years) Page 4 of 25 Brief description of the care home needs. All bedrooms are single occupancy with en suite facilities which include toilet, hand basin and shower facilities. People using the service are encouraged to personalise their own rooms to meet their personal preferences. Communal areas are spacious, light and airy, and include two separate activity rooms. The garden provides a safe recreational area which is easily accessed from the ground floor. There are both stairs and a passenger lift to gain access to upstairs. Information about fees can be obtained from the provider. Care Homes for Adults (18-65 years) Page 5 of 25 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: Before we visited the service the manager sent us the Annual Quality Assurance Assessment which tells us about their plans for development for the year. We visited the service on a week day and spent time with a person who lives there, the manager and staff. We also looked at some records. Our judgements are based on the experience of one person because other people have not moved to the service yet. Care Homes for Adults (18-65 years) Page 6 of 25 What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Adults (18-65 years) Page 7 of 25 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 8 of 25 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are confident that the service can support them, because they have an assessment of their needs that they, or people close to them, have been involved in. This tells the service all about them and the support they need. Evidence: The Annual Quality Assurance Assessment tells us that people receive the guide to the service during the period before they move when they are getting to know the service. The guide is user friendly in pictorial, symbol and simple language, and the staff explain its contents. The guide explains the terms and conditions of living at Abbey croft and the service that will be provided to them by Edgeview Homes. The manager tells us they plan to produce an audio guide for people who may prefer to use this. The guide and statement of purpose contain all the information required by the National Minimum Standards, including what the service is, what to expect, fees, staff, fire safety, rights, protection from abuse and complaints. The guides are on display in communal areas of the house. One person using the service tells us they had good information before they moved. Care Homes for Adults (18-65 years) Page 9 of 25 Evidence: The Annual Quality Assurance Assessment tells us that people have an assessment of their needs, desires and aspirations which helps them to influence the direction of their care. The service uses an assessment based on a well known research model for people with learning disabilities. The assessment looks at, for example, people skills, physical and mental health, interests, domestic and social needs, cultural needs, and perceptions of themselves and others. A large part of the information is from varied health professionals such as nurses and occupational therapists. People using the service are able to see health professionals and therapists employed by the service as well as keeping appointments with their own doctors and other professionals. The Annual Quality Assurance Assessment tells us that Any special needs of the individual including cultural, social, or personal are fully discussed, documented and included in the care and support plans, and any potential restrictions on choice, freedom, services or facilities are all risk assessed. One person using the service tells us they were able to visit several times before moving, and had the choice to have an overnight stay. The records show that this persons move to the service was carefully planned to take into account their wishes and cause little disruption. We saw that people have a contract of terms and conditions that they sign if they are able to. Care Homes for Adults (18-65 years) Page 10 of 25 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples needs and goals are met because they have a detailed plan of support that they or someone close to them has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. People are supported to take risks to enable them to stay independent. This is because the staff have good information on which to make decisions. Evidence: The Annual Quality Assurance Assessment tells us that peoples support plans are agreed by the person and by the health professionals involved in their support. It says that all support plans are unique for each person and include their needs and personal goals, staff interventions, rehabilitation and therapeutic programmes. We saw that peoples plans are set out clearly so that staff know what to do to support people for each of their needs and goals. We looked in detail at one persons plan which shows that it is very specific to that person. The plans relate to specific events and decisions as well as general care and support needs. The plans also describe any restrictions on choice and freedom imposed by a specialist programme as necessary. Care Homes for Adults (18-65 years) Page 11 of 25 Evidence: Peoples plans are very detailed with notes under each section from staff every day. All sections are regularly reviewed, most updated in the past month which shows the development of peoples support in the early days they are using the service. People have key workers who write monthly diaries which shows peoples development and progress. The person whose plan we saw has been reading through and signing sections as they read them. We discussed with the manager the need to have different versions of peoples plans so each plan is accessible for that person, for example it may be necessary to summarise or simplify for some people or provide a different format. The manager says that each individuals needs will be considered as they move in. As the service is new peoples plans are very much based on the needs suggested by health and other professionals. We also discussed with the manager how people might be supported to contribute to their own support plan, in their own words, for example through writing a life story, a plan for their ideal day, or other ways to show what is important to them. The notes in the support plans show that staff are able to support people to make decisions. Specific care plan sections are set up relating to particular decisions if they are very significant. This records peoples decision making and how staff have supported them. The plans show how peoples money is kept safe by the service and how independence with finances is supported. The language in the plan is supportive for example, opportunities to be presented slowly and then with increased pace. Give limited choices at first to help become familiar and more confident. The Annual Quality Assurance Assessment tells us that people using the service are encouraged to take an active part in life at Abbey croft and the day to day running of the home. There are regular meetings where people can share their views and suggestions for improvements. People are able to be involved in staff recruitment as they wish. People are supported to take risks as part of their personal development. Risk assessments are included in peoples support plans so it is clear to staff and people using the service what the risks are relating to. A scoring system is used, and staff are confident how to use this system and how to support people to take risks. The Annual Quality Assurance Assessment tells us that people using the service are aware that their support plans are safely stored centrally to ensure confidentiality and that at any time they can access or receive a copy of their plan. Care Homes for Adults (18-65 years) Page 12 of 25 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Each person is treated as an individual and they can take part in activities that are appropriate to their age and culture. They are part of their local community and are able to keep in touch with family, friends and representatives. The service supports people in their relationships. People have healthy, well presented meals and snacks, at a time and place to suit them. Evidence: The Annual Quality Assurance Assessment tells us that people benefit from opportunities to develop existing interests and experience new activities and to reach their optimum level of independence. We looked at one care plan which shows concern for personal development, which will be developed as the person continues to live at Abbey croft. The provider organisation employs their own sessional therapists and health professionals related to peoples needs, and people continue to receive input from their existing community teams. Care Homes for Adults (18-65 years) Page 13 of 25 Evidence: The Annual Quality Assurance Assessment tells us that the Activity Rooms at Abbey croft will be used for art and craft, literacy and numeracy, computer skills, music therapy, keep fit, relaxation and when appropriate holistic alternative therapies. Peoples skills will be assessed and monitored as they progress. People will be actively encouraged and supported to pursue engagement in external work placements, on training courses and to attend colleges to further their skills and knowledge. As the service is new there has been limited opportunity for this area to be developed so far, but we see that detailed care plans support the wishes of the people using the service. For example, one person has expressed an interest in food and food hygiene, and will be attending the food hygiene course with staff. A person who uses the service also tells us that they have been able to get out and about using public transport and the car owned by the service. This person told us how important it is that they are active and get out of the house, and we could see from daily records that this is being respected. This person also showed us their weekly activity plan which they make every week with support from staff. Plans and daily records show a mixture of leisure activities that can be built on over time. Residents meetings notes show that people feel comfortable making requests about their leisure time for example having satellite TV. The Annual Quality Assurance Assessment tells us that contact with all family and friends is kept as desired, they are welcomed at any time. People are able to develop and maintain relationships with people of their choice, any restrictions in this area being agreed and clearly documented in the support plan. The person we met tells us they see their family once a week and have been supported to keep in touch with old friends. People using the service are assisted by staff to complete a Daily Living Skills Assessment which highlights their strengths and areas for improvement, and leads to an action plan of long and short term goals. Support with skills includes food shopping, storage, preparation and cooking, cleaning, laundry and personal hygiene. We saw that an activity planner includes cleaning the house, and cooking meals. We note that people are able to have their own key to their room. We saw that meals are recorded, which shows variety and healthy food, and peoples likes and dislikes accounted for. One person tells us they enjoy the food and help with some meals. Care Homes for Adults (18-65 years) Page 14 of 25 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. Evidence: The Annual Quality Assurance Assessment tells us that peoples support plans are regularly reviewed to reflect the peoples changing needs. We saw one persons support plan which is very detailed and shows clearly the tasks for staff and what support is required. The plans are written in supportive language for example, staff to build trust, offer a consistent approach and clear instructions if X expresses concerns, fear or anxiety. In the different sections of the plan we note examples of staff discussing the plan with the person where concerns are raised. We also note that the plan show awareness of a persons needs in relation to their ethnicity. The Annual Quality Assurance Assessment tells us that staff support people to attend regular health checks and to access community health services such as the dentist, optician, chiropodist and well person clinic. People are referred to the appropriate specialist Care Homes for Adults (18-65 years) Page 15 of 25 Evidence: support to meet their healthcare needs. The person we met was still very new to the service and had not yet been registered with local services, for this reason had not yet set up a Health Action Plan. However we can see from daily notes that the person has been involved with all meetings with health practitioners and their view is recorded at all stages. We note that recordings by night staff are very detailed and it is agreed with the person every night how regularly they are checked, which is good practice. We discussed with the manager how an appropriate planner for health appointments would be useful, so that people are able to take some opportunity to manage their own health care as far as possible. The Annual Quality Assurance Assessment tells us that the service gains the consent of the person to administer medication which s documented in the relevant support plans. There are policies and procedure in respect of the Receipt, Recording, Storage, Handling, Administration and Disposal of Medicines. Staff undertake accredited training in the Administration of Medication. Following training staff are supervised and observed in relation to all aspects of the medication administration until they are confident and competent. Peoples support plans show explanations of what the medications are for and potential side effects. The medications cabinet and recording shows appropriate use and storage. Care Homes for Adults (18-65 years) Page 16 of 25 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. If people have concerns with their care, they or people close to them, know how to complain. The care home safeguards people from abuse, neglect and self harm. Evidence: The service has a comprehensive complaints policy which clearly identifies social services, CSCI and other parties involved as necessary. The policy is kept in the Policy and Procedure file, as well as in the main entrance hall of the home and within both the Statement of Purpose and Guide. We see from meeting notes that complaints are always on the agenda for resident meetings. The Annual Quality Assurance Assessment tells us that peoples family and friends are given a copy of the complaints policy. We spoke to one person using the service who tells us that they know what to do if they are not happy and says that their concerns are always listened to. We note that the service also has a clear adult protection policy in place, and that staff are aware of the safe guarding process and what to do if they are concerned about someone they support. We looked at staff files and can see that the service follows the correct recruitment procedures. Staff have also had recent adult abuse training and all staff have two days non violent crisis intervention training. Care Homes for Adults (18-65 years) Page 17 of 25 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People stay in a safe and well maintained house that is homely, clean, comfortable, pleasant and hygienic. Evidence: The Annual Quality Assurance Assessment tells us that people are encouraged to personalise their rooms to meet their personal preferences. All bedrooms have a lock, and people retain their own key. Communal areas are spacious, light and airy, and the activity rooms provide adequate space for people to engage in planned activities and those of their own choosing. The landscaped garden provides a safe recreational area. There are stairs and a passenger lift which provides for ease of access to the upper floors, access to the garden area is by two exit points on the ground floor. We note that one bedroom is very personalised according to the persons wishes and expect that the communal area of the house will become more personalised as people move in, for example with photographs. Records show that the service has the appropriate health and safety policies and procedures and staff have had training in infection control and food hygiene. We observe that staff adhere to hygiene training and practices. Care Homes for Adults (18-65 years) Page 18 of 25 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have safe support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff because checks have been done to make sure that they are suitable. Peoples needs are met and they are supported because staff get the right training, supervision and support they need from their managers. Evidence: The Annual Quality Assurance Assessment tells us that staff are aware of the aims and objectives of the home and have clear roles and responsibilities within it. All staff are given job descriptions and receive full induction training. Staff are aware of the need to work closely with different health and therapy professionals. We met staff who were able to talk about their role and are knowledgeable about the people they support. The Annual Quality Assurance Assessment also tells us that the service is committed to staff development through NVQ training. Plans for the next 12 months include for all personal assistants to start working towards NVQ level 3. Staff are selected on the basis of their ability to be caring, supportive, non judgemental and consistent in their approach. All people using the service receive a minimum of one to one staffing from 08.00 AM to 21.00 PM each day. Some people using the service may require two to one support which is offered. Night staff are waking and the home manager is supernumerary. There is always one trained nurse on duty and 30 per cent of the staff Care Homes for Adults (18-65 years) Page 19 of 25 Evidence: team are male, with one female staff member on duty. Staff numbers will be increased as people move to the service. We saw staff files which show a good recruitment procedure, for example two satisfactory written references are obtained, one of which is from the last employer. New staff are only confirmed in post following completion of a satisfactory POVA check and in the case of a registered nurse confirmation of current Nursing Midwifery Council registration. All staff are employed on a three month probationary period, receive a contract of employment and a copy of the General Social Care Council Code of Conduct and Practice. We note that there is one new staff member whose criminal records document has not been returned. We discussed this with the manager who showed us that this person has received the minimum checks, has worked through an induction and is being supervised until the final check comes through. The manager understands that this process must only occur in exceptional circumstances such as in this case, to allow the first person to move to the service in a timely way. Staff files show that all staff have an induction during which mandatory training is undertaken. Induction follows the common induction standards and the manager tells us they will be adopting the Skills for Care Induction for all new staff. Staff training is ongoing and makes sure they have the knowledge, competency and skills to meet the complex needs of people using the service. Records show that the manager monitors staff training and has been concentrating on mandatory health and safety training while the service is new. The manager has had local authority training on the Deprivation of Liberty Standards and staff will be having this training in future. Staff tell us they feel competent to do their jobs and are well trained to manage the challenges of their job. The Annual Quality Assurance Assessment tells us that staff handover is carried out three times per day at shift changes. Staff receive regular supervision a minimum of six times per year and an annual appraisal to review their performance and identify any training needs. Staff meetings take place every six to eight weeks all are fully documented. Staff say they are confident in their jobs and get full support from their managers, including regular supervision and support at other times. Care Homes for Adults (18-65 years) Page 20 of 25 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have confidence in the care home because it is run and managed well. Peoples opinions are a large part of how the service develops. The environment is safe for people and staff because health and safety practices are carried out. Evidence: The registered manager is a trained learning disability nurse with experience in caring and supporting people with learning disabilities and complex needs. She is currently undertaking her Registered Managers Award which she expects to finish this year. The Annual Quality Assurance Assessment tells us that the needs of people using the service are central to the operation and development of Abbey croft. It says the service takes a person centred approach to developing a service that meets requirements, there is an open door policy and a commitment to equal opportunities and relationships between service users and staff are of mutual trust and respect. The provider carries out an annual quality assurance audit which looks at quality of life for people using the service (including choice, rights, fulfilment, independence, privacy Care Homes for Adults (18-65 years) Page 21 of 25 Evidence: and dignity), the quality of the care and the quality of the management. The service gains peoples opinions through annual questionnaires, monthly meetings which are chaired by people using the service and involvement of people in the staff selection and interviews process. We note that all policies and procedures are in place, for example we looked at the complaints, adult protection, medications and health and safety policies in detail. All of these policies are appropriate and accessible by staff. We note that all records kept by the service the staff are up to date and in good order. The Annual Quality Assurance Assessment tells us that staff have all had training in safe handling and moving, food hygiene, infection control and fire prevention awareness and action to take in the event of a fire. Staff receive appointed person first aid training, and a first aider is on each shift. The servicing of essential equipment is up to date and accurately recorded including fire equipment, emergency lighting, gas and electric supplies, water, storage of hazardous substances. We saw that environmental risk assessments are completed, and note that the service has responded appropriately to a health and safety query relating to their spa baths. One person using the service is to be nominated as a link health and safety representative which is good practice. Care Homes for Adults (18-65 years) Page 22 of 25 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 23 of 25 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 6 As people move in, the service should consider different versions of their support plans so each plan is accessible for the individual, for example it may be necessary to summarise or simplify for some people or provide a different format. The service should consider how people can be supported to contribute to their own support plan, in their own words, for example through writing a life story, a plan for their ideal day, or other ways to show what is important to them. The service should consider setting up an appropriate planner for health appointments and other health care information, so that people are able to manage their own health care as far as possible. 2 6 3 19 Care Homes for Adults (18-65 years) Page 24 of 25 Helpline: 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 We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). 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