Care Home: Abbeywood

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What the care home does well The needs of people who are thinking of moving into the home have been thoroughly assessed, to ensure these can be met. These needs have then been used to draw up a detailed service user plan, which provides staff with guidance as to the support and care necessary to meet those needs. People living at the home are offered a wide range of social and leisure activities, and are supported to maintain contact with their friends, family and the community. The routines of the home are flexible and aim to meet the preferences of those living there. A varied and well balanced selection of meals are offered to residents, including seasonal and festive items. These are a served in small, family-sized dining rooms, at tables that were set with tablecloths, napkins and flowers. Meals are served in alternative forms if required and specialist food supplements had been obtained for those residents requiring them. People living at the home, and those involved in their support, can be confident that any complaints will be listened to and acted on. Staff working at the home were aware of their role and responsibilities in protecting residents from abuse. The home is decorated and furnished in a colourful and attractive style. It appeared well maintained, was clean, orderly and very freshly aired, which gave no indication of the high personal care needs of some of the people who live there. A full team of staff are employed to meet the needs of residents, and the required checks have been carried out to ensure the staff are suitable to work in a care home. Staff have received an induction into their role and responsibilities, have received training required by law (mandatory training), and other training. This is to ensure that staff have the knowledge and skills, to provide the required standard of care and support to residents, and to enable them to develop and progress their role within the home. People living at the home continue to benefit from an effective management team, who ensure that the home is run in the best interests of all those living there. The home is managed in an open way and the senior team are freely accessible to residents, visitors and staff. What has improved since the last inspection? The hours worked by activities staff in the home have been reviewed to ensure they are enough to meet the social and cultural needs of the people living in the home. Although the complaints procedure has not been changed, it was clear that it is meeting the needs of people living in the home, as they know who they can speak to if they are unhappy or dissatisfied and only two formal complaints have been received in the past year. When people apply to work in the home, their entitlement to work in this country has been confirmed. A record has been maintained and kept in the home of the induction of new staff, to ensure they are aware of their role and responsibilities. What the care home could do better: The contracts or statement of terms and conditions for living at the home must advise residents of the fees that they must pay, or that others must pay on their behalf. Although medication in the home was accounted for, it is good practice to maintain records that enable a clear audit trail to be followed. This will ensure that medication can be fully monitored to safeguard residents. CARE HOMES FOR OLDER PEOPLE Abbeywood Abbeywood Wharf Road Ash Vale Surrey GU12 5AX Lead Inspector Sandra Holland Unannounced Inspection 11:00 7 February 2008 th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Abbeywood DS0000013544.V359120.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Abbeywood DS0000013544.V359120.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbeywood Address Abbeywood Wharf Road Ash Vale Surrey GU12 5AX 01252 317132 01252 323732 N/A sharon.blackwell@anchor.org Anchor Trust 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) Mrs Alexandra Strong Care Home 50 Category(ies) of Dementia - over 65 years of age (21), Old age, registration, with number not falling within any other category (12), of places Physical disability over 65 years of age (15) Abbeywood DS0000013544.V359120.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The age/age range of the persons to be accommodated will be: 65 YEARS AND OVER Up to twenty-one (21) residents may be within the category DE(E) Dementia - over 65 years of age. Up to fifteen (15) residents may be within the category PD(E) Physical Disability over 65 years of age. Date of last inspection Brief Description of the Service: Abbeywood is a purpose built home located in the residential area of Ash Vale and is located next door to the local health centre. The Home is managed by the Anchor Homes Trust and is registered to care for 50 residents over the age of 65. Up to 21 residents may experience dementia and up to 15 residents may have a physical disability. A Manager, Deputy Manager and a team consisting of care staff, catering, domestic, administration and maintenance staff are employed to meet the needs of residents. The home is divided into five separate units each comprising of a lounge/dining room with its own kitchen area where refreshments can be provided. Residents are accommodated in single bedrooms that are all close to communal bathroom and toilet facilities. The home has a private, central courtyard garden that is secure and accessible to residents. A limited amount of car parking is available for visitors. The fees at Abbeywood range from £350.00 per week to £720.00 per week. Abbeywood DS0000013544.V359120.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 3 star. This means the people who use this service experience excellent quality outcomes. The Commission has since the 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the service was an unannounced “Key Inspection”. The inspector arrived at the service at 11.00 and was in the service for seven and a quarter hours. It was a thorough look at how well the service is doing. It took into account detailed information provided by the service’s manager, and any information that CSCI has received about the service since the last inspection. Mrs. Sandra Holland, Regulation Inspector carried out the inspection and Mrs. Alexandra Strong, Registered Manager represented the service. A tour of the home was carried out and most areas were seen. A number of records and documents were sampled including medication administration records, individuals’ care plans, staff recruitment and training records. Fifteen residents, three visitors and eight members of staff were spoken with during the course of the inspection visit. An annual quality assurance assessment (AQAA) was supplied to the home and this was completed and returned. Information supplied in the AQAA will be referred to in this report. Information supplied in the AQAA indicated that equality and diversity is promoted in the home by recognising and responding to individual’s rights of choice, privacy, dignity and independence, and these are reflected in the service user plan. To ensure staff are aware of equality and diversity issues, this is incorporated into the “Rights and Responsibilities” training that staff receive. The people living in the home prefer to be known as residents and that is the term that will used in this report. The inspector would like to thank residents and staff for their time, hospitality and assistance. Abbeywood DS0000013544.V359120.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? The hours worked by activities staff in the home have been reviewed to ensure they are enough to meet the social and cultural needs of the people living in the home. Abbeywood DS0000013544.V359120.R01.S.doc Version 5.2 Page 7 Although the complaints procedure has not been changed, it was clear that it is meeting the needs of people living in the home, as they know who they can speak to if they are unhappy or dissatisfied and only two formal complaints have been received in the past year. When people apply to work in the home, their entitlement to work in this country has been confirmed. A record has been maintained and kept in the home of the induction of new staff, to ensure they are aware of their role and responsibilities. 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. Abbeywood DS0000013544.V359120.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Abbeywood DS0000013544.V359120.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6. People who use the service experience good outcomes in this area. People living at the home have been provided with a contract detailing the terms and conditions for living there, but some of these did not specify the amount of fees that the resident, or others, must pay. The needs of prospective residents have been assessed in detail before they moved in, including social and leisure needs. This is to ensure that these could be met in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People who have moved into the home since the last inspection have been provided with, and signed, a contract with the home, so that they are aware of the terms and conditions for living there. It was noted these did not specify the information regarding the fees payable. The manager advised that in some Abbeywood DS0000013544.V359120.R01.S.doc Version 5.2 Page 10 cases, residents receive financial support from a local authority and their residence at the home is funded under a contract with the authority. It is required that this information is supplied to residents before they move in, or on the day they move in, to ensure that they are fully aware of the terms they are agreeing to live under, regardless of who is providing the funding. A detailed assessment had been carried out of the needs of prospective residents, as this enables the home to know if they can meet the resident’s needs. These were seen to include reference to risks to the safety and welfare of residents, such as the risks of falls. It was positive to note that the assessments also recorded the social and leisure interests of prospective residents, as this would enable the home to know if it could meet these needs. Some residents had visited the home for an assessment day and other residents had been visited at their home or previous place of residence. A prospective resident was spoken with on the day of inspection and they explained that they had come to visit for the day, to see if they liked the home and whether it suited and could meet their needs. The manager advised that experienced senior staff oversee the assessment of prospective residents’ needs, although care staff may gather and record the information, during a resident’s assessment day at the home. It was noted that two of the four assessments that were seen, had been signed by members of the care staff team. It is recommended that senior staff countersign these to show that they have been involved, as the needs of prospective residents should only be assessed by suitably qualified or suitably trained staff. The manager advised that intermediate care is not provided at the home, so Standard 6 does not apply and has not been assessed. Abbeywood DS0000013544.V359120.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People who use the service experience good outcomes in this area. People living at the home can be assured that staff are provided with detailed information about their needs and with clear guidance as to how their needs should be met. Residents’ healthcare needs are well met and they are safeguarded by the home’s procedures and practices of medication administration. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A new style of service user plan has been introduced in the home during the last year, staff advised. Four of these were sampled, including those for people who had recently moved into the home and for a resident who had lived there for a number of years. Each service user plan contained comprehensive information about the resident, including their needs in relation to communication, mobility, personal care, social activities, healthcare and eating and drinking. The plans also guided staff to the support required to meet Abbeywood DS0000013544.V359120.R01.S.doc Version 5.2 Page 12 those needs and the plans and been regularly reviewed and updated. This is to ensure that they reflect any changes in the needs of residents. It was positive to observe that each of the service user plans seen had been signed by the resident to show their involvement in developing it. Most residents had also signed to give their consent to other aspects of their care, such as having their photograph taken, having their medication administered by staff or not, and the frequency of night-time checks they wished to be carried out. Risks to the health or welfare of residents had been assessed and recorded, such as the risks associated with mobility, including falls. Information was provided in the plans to guide staff in reducing these risks, such as two staff providing support to a resident who had mobility problems, or by the use of specialist equipment. Where specific risks have been noted to individual residents, these have been assessed and recorded, again including actions to minimise the risk wherever possible. It was clear from the records seen and speaking to residents and staff that the healthcare needs of people living in the home are well met. Records seen indicated that a number of healthcare professionals are involved in the support of residents. These include general practitioners (GP’s), community nurses, a chiropodist, community psychiatric nurses (CPN’s) and hospital specialists. The procedures and practices of medication administration appeared to be effectively managed, and the required records maintained to safeguard people living in the home. Medication was seen to be appropriately stored in locked provisions, and a lockable fridge was available for medication requiring chilled storage. Access to medication is restricted to the management team and senior staff and the deputy manager stated that she takes the lead in ordering medication supplies, with the support of another member of the senior team. For those residents who wish to administer their own medication, lockable facilities are available and any risks associated with this are assessed, recorded and minimised if possible. The amounts of a number of medications were randomly sampled, were checked against the records held, and these were seen to accurately match. It was noted that for a number of medications, the amount held had not been carried forward onto new medication administration record (MAR) charts, so it was not easy to follow an audit trail. It is recommended that all stocks of medication held are carried forward, as this enables an audit trail to be clearly followed. This helps to further safeguard residents and their medication, and assists with monitoring stock. Abbeywood DS0000013544.V359120.R01.S.doc Version 5.2 Page 13 It was positive to observe staff treating residents with respect, and speaking to residents in a relaxed and friendly, but appropriate manner. Resident’s privacy was seen to be promoted, with staff taking care to knock on resident’s bedroom doors before entering and offering or providing personal care in a tactful and discreet way. Abbeywood DS0000013544.V359120.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People who use the service experience excellent outcomes in this area. People living at the home are offered a wide range of social and leisure activities and are supported to take part in these. They are also encouraged to maintain contact with their families and friends, and visitors to the home are welcomed. A selection of well balanced and appetising meals are offered to residents and these are served in attractive and comfortable dining rooms. This judgement has been made using available evidence including a visit to this service. EVIDENCE: It was very positive to observe that a weekly activities programme was displayed in each unit and in the entrance hall, to advise people living in the home of the range of activities taking place that week. These had been dated to show which week they related to and included seasonal events, such as pancake making, as Shrove Tuesday occurred during the week of the inspection visit. It was also positive to note that each activity programme was presented in words and pictures to suit the differing needs of residents. Information supplied in the AQAA advised that two activities co-ordinators are employed in the home to support residents with social and leisure activities, Abbeywood DS0000013544.V359120.R01.S.doc Version 5.2 Page 15 and that individual and group activities are encouraged. The activities programme included cake and sweet making, musical events, dominoes, pampering sessions, arts and crafts, and bingo. Larger events, such as a Christmas fete and party are arranged in the home. Staff advised that a visiting farm would be coming to the home later this month, so that residents could enjoy seeing, holding and stroking the animals. Staff advised that some social activities are held on individual units, whilst others take part in the large activities room near the main hall. This room is equipped with tables and chairs to enable groups of residents to take part in activities together, as well as armchairs and musical facilities. Trips out of the home are also arranged and these included pub lunches and going to the pantomime and theatre. From speaking to residents and visitors, it was clear that people living in the home are helped to maintain contact with their families and friends. A number of residents advised that they have their own telephone to enable them to keep in touch with others outside the home. Visitors advised that they are made very welcome in the home and can visit at any time. Residents advised that they were encouraged to make their own choices and decisions in as many aspects of their lives as possible. Residents said they could get up and go to bed as they wished, and could take part in the activities or spend time in their room, as they preferred. Residents had been offered keys to their bedrooms, and forms in their service user plans, which residents had signed, recorded their decision. Residents are also offered a choice at each meal time, as meals are not ordered in advance. The menu was seen to be displayed on each dining table, so that residents were aware of the meal to be served, as well as being displayed in the entrance hall. The lunchtime main course choices on the day of inspection were braised pork chop and vegetables, or chicken with ginger, spring onion and noodles, which was offered to mark the beginning of the Chinese New Year. Dessert options included chocolate sponge with vanilla sauce, fruit salad, ice cream or yoghurt. Staff advised that meals are served in alternative forms, such as pureed, if necessary to meet residents’ needs, and specialist food supplements had been obtained for those residents requiring them. Residents were spoken to as they finished their meal, and all said how much they enjoyed it, that it was hot when served and that they appreciated the choices. Staff were available to assist residents with their meals if required, but were seen to encourage residents to be independent wherever possible. Each unit has its own dining room and these were furnished in a homely style with tables seating up to four residents. Tables were attractively set with colourful tablecloths and napkins, which residents advised were new, and with glasses and flowers. Abbeywood DS0000013544.V359120.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People who use the service experience good outcomes in this area. Only a very small number of complaints have been received and these have been dealt with appropriately, so residents can continue to be confident that they will be listened to. Staff have received training in safeguarding adults and were aware of their responsibilities in the protection of residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A requirement was made following the last inspection that the home’s corporate complaints procedure must be reviewed and must be suited to the needs of residents. This was because the main part of the procedure requests anyone wishing to make a complaint, to write to the Anchor organisation’s office. As many of the residents in the home are either very frail, experiencing dementia or have a physical disability, this may present as a barrier to them making their views known. Whilst no major changes have been made to the procedure, it was seen to be widely available in the home, including in the entrance hall, on the notice board in each unit and in the service user’s guide, which is provided to each resident. As only two formal complaints have been received during the last year, and no information has been passed to CSCI about any complaint made Abbeywood DS0000013544.V359120.R01.S.doc Version 5.2 Page 17 to the home, it is accepted that the current complaints procedure is meeting the needs of residents. The manager advised that as she and her senior team are in day to day contact with residents and their families, any areas of dissatisfaction or unhappiness are dealt with immediately to prevent them developing into formal complaints. The management team were observed to interact with a number of residents and visitors in a friendly, informal manner, whilst maintaining respect. Visitors advised that there was an open atmosphere in the home, and they could speak to the management team if they had any concerns, but had never needed to do so. It was positive to hear senior staff advise that the home receives many letters and cards of thanks and commendation, from appreciative residents and their families and friends. In the event of any concerns being raised about suspicions or allegations of abuse, the home would follow the Surrey Multi-Agency safeguarding Adults procedure, the manager stated. An up to date copy of the procedure is kept in the home for staff to refer to if needed. The home has made referrals under this procedure in the past and all appropriate actions were taken. A number of staff were spoken with and all advised that they understood about abuse and said they would report any concerns to the manager or person in charge. From the staff training records it was noted that most of the staff working in the home had received training in safeguarding adults and almost all staff had received training in Rights and Responsibilities. Staff meetings are used as an opportunity to emphasise to all staff that whistle-blowing is a confidential process, and the importance of reporting any concerns, the manager advised. Abbeywood DS0000013544.V359120.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. People who use the service experience excellent outcomes in this area. People living at the home benefit from a safe, well-maintained and comfortable environment. It is attractively decorated and furnished, is kept clean and very freshly-aired. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Although the home is registered to provide accommodation and care for up to fifty people, residents live in smaller family style units, each with its own lounge, dining room and kitchen areas. It was observed that each unit was decorated and furnished in different colours, some had a different layout and each had developed an individual character. Abbeywood DS0000013544.V359120.R01.S.doc Version 5.2 Page 19 Information supplied in the AQAA stated, “there is a home maintenance programme in place as part of the business plan to ensure continuous improvement”. Most areas of the home were seen during the tour of the home, and it was clear that an on-going programme of improvement is carried out. All areas of the home were attractively decorated, comfortably furnished in a homely style and appeared well maintained. Residents who were spoken with said they were happy with their bedrooms and had been able to bring their own things in when they moved into the home, to make their rooms more personal. Each resident has a single bedroom that is fitted with a wash-hand basin, and in a number of bedrooms, the basin and surrounding unit was being replaced. These had become worn the manager advised, and also included a high cupboard which was not very accessible for many residents. The new basins were being fitted into lower vanity units, so that they would be easier for residents to use. Staff advised that the area around each new basin and unit was being decorated when the fitting was completed. Since the last inspection, alterations have been made to the separate lounge and dining rooms on one unit, to create one large room. Staff advised that this made it easier for residents to see what was going on and opened up the space so that there was more room to arrange social and leisure activities for residents. Further information in the AQAA indicated that it is planned to alter the layout of some toilets and bathrooms in the home, to make them more spacious and easier for residents to use. The home was clean, very well presented and appeared hygienic. Staff advised that they are provided with personal protective equipment, including gloves and aprons, and these are used to maintain hygiene and prevent infection. Hand-washing facilities were equipped with liquid soap and paper towels and were provided in appropriate places. Information in the AQAA indicated that all staff have received training in infection control, to ensure they understand current good practice in maintaining effective hygiene standards, and the actions to take to prevent infection or to prevent the spread of infection. It was very positive to note that the home was freshly aired throughout, which gave no indication of the high personal care and support needs of a number of residents. Abbeywood DS0000013544.V359120.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People who use the service experience good outcomes in this area. People living at the home are protected by the home’s recruitment policies and practices, and are supported by a full team of staff who are well trained. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information supplied in the AQAA indicated that residents are supported and cared for, by a full team of staff. The team consists of care staff, catering staff, housekeeping staff, laundry staff, a maintenance person, a receptionist and administrators. A number of staff from a variety of roles were spoken with during the course of the inspection visit. It was positive to hear that they enjoyed working at the home, appreciated the training opportunities that are provided and were enthusiastic about providing a quality service. Almost half of the care staff have achieved a National Vocational Qualification (NVQ) to level 2 or higher, and a further nine staff are working towards this qualification, so the home is on target to achieve the recommended 50 of care staff trained to this level. Residents are protected by the home’s recruitment policies and practices. The files of a number of recently recruited staff were seen and the specified records Abbeywood DS0000013544.V359120.R01.S.doc Version 5.2 Page 21 and documents had been obtained, including two written references and a Criminal Records Bureau (CRB) disclosure. These had been obtained to ensure that staff are fit to work in the home. A general staff training plan is maintained, in addition to individual staff training records. These confirmed that staff receive training required by law (mandatory training), including fire safety, first aid and food hygiene, and other training to develop knowledge and skills, such as dementia care, continence promotion and the Control Of Substances Hazardous to Health (COSHH). It was positive to note that staff receive training that is appropriate to their role, and staff advised that they are provided with opportunities to develop and progress their roles within the home. Catering staff have received food hygiene training, and housekeeping and maintenance staff have received training in health and safety and said they were due to receive COSHH training shortly after the inspection visit. Records of the induction received by staff were also seen. These recorded that staff had been advised of their role and responsibilities, and of the policies and procedures that they work under. Abbeywood DS0000013544.V359120.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. People who use the service experience excellent outcomes in this area. It is clear from the good outcomes experienced by people living in the home, that it continues to be effectively managed and run in the best interests of those living there. The procedures for managing residents’ monies that are held for safekeeping ensure that residents are safeguarded from financial abuse. The health and safety of all those living and working in the home is promoted and protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: From all the information gathered, and from speaking to residents and staff, it was clear that the home continues to be effectively managed and is providing Abbeywood DS0000013544.V359120.R01.S.doc Version 5.2 Page 23 excellent outcomes for the people living there, as assessed during this key inspection. The home is run and managed by a person who has many years experience in care and management, and is fit to be in charge. The manager is capably supported by a management team, made up of a deputy manager, a team of senior care staff and a chef manager. It was positive to note that the enthusiasm and commitment of the management team that was displayed at the last inspection visit, was still clearly evident. The manager stated that the views of residents are obtained to ensure the home is being run in the best interests of those living there. This is achieved in a number of ways, including surveys, resident meetings and by the day-today contact between residents and the management team. Quality assurance surveys are being supplied to residents on a unit-by-unit basis, and are being to supplied to visitors when they come into the home, the manager advised. A separate catering survey is carried out each month and a record of the survey carried out in January 2008 was seen. Staff advised that the chef maintains regular contact with residents to obtain their feedback on the meals provided. The administrator advised that monies can be held for safekeeping if required by residents. To ensure these are safeguarded, only administrative or senior staff have access to these and two signatures are recorded for each transaction. Staff advised that a new computer based recording system has been introduced since the last inspection, and detailed written and computer records were seen. The amounts recorded were noted to accurately match. Residents are also provided with a lockable facility in their bedrooms, in which to store any valuables. Information was provided in the AQAA to confirm that maintenance and service checks are carried out on systems and equipment in the home, to protect and promote the health, safety and welfare of all those who live and work there, and no hazards were noted during the tour of the premises. Abbeywood DS0000013544.V359120.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 Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 4 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 3 X 3 X X 3 Abbeywood DS0000013544.V359120.R01.S.doc Version 5.2 Page 25 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 OP2 Regulation Requirement Timescale for action 09/05/08 5A (2 & 3) Each person who became a resident after 1st September 2006, must be supplied with a statement specifying the fees payable by, or in respect of the resident, for the provision of any of the following services – (i) accommodation, including the provision of food; (ii) nursing; and (iii) personal care. 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 OP9 Good Practice Recommendations It is good practice to maintain medication records that enable a clear audit trail to be followed. Abbeywood DS0000013544.V359120.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Abbeywood DS0000013544.V359120.R01.S.doc Version 5.2 Page 27 - 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. 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