Care Home: Abbingdon House

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What the care home does well The procedure for obtaining assessments information for people who may come to live at Abbingdon assists in meeting the needs of people. The people who use the service have their needs met by the way the service devises and reviews care plans. Their health is maintained with the support of health professionals and by the way medication is managed. People have their privacy respected by the staff team. The people who use the service are able to pursue their daily routines and maintain links with their family and the community. People are encouraged to be as independent as possible. The meals provided at the service meet the nutritional needs of people as well as their preferences. The people who use the service have the information they need on how to raise any concerns they have about the support they receive. People are protected by the service’s policies, procedures and training provided to staff. The people who use the service live in a home like environment which is hygienic.Abbingdon HouseDS0000018851.V378183.R01.S.docVersion 5.2The people who use the service are supported by staff that are in sufficient numbers to meet their needs, are qualified and trained to meet their needs. The recruitment process protects individuals. People receive support from a well managed service that takes their views into account. Their financial interests are safeguarded by the service. Comments made during the visit included: ‘I am feeling fine but if I am not well they will get a Doctor’ ‘They look after me’ ‘I get out and about and can see my friends form the local church every week’ ‘The meals are fine and you can order alternatives if you do not like what’s on offer’ ‘I can keep in touch with my family’ ‘It is alright I love it here’ ‘I like my room’ ‘I have no complaints but if I did I would see the Manager’ ‘Staff are lovely, they help me’ ‘Staff listen to us’ ‘I have always been an early riser and staff let me do what I want’ ‘I get my privacy’ ‘We are treated with respect here’ ‘We are happy with this place-staff are good and they have done well with my relative’ ‘Staff are wonderful and they always let us know if things happen’ ‘My relative is well looked after and the place has been of benefit to them’ What has improved since the last inspection? The service now ensures that the people who use the service are protected through the provision of training for staff in safeguarding vulnerable adults. The service now ensures that the recruitment process protects individuals who use the service. The service has now improved the way it gains the views of the people who use the service. What the care home could do better: The service must ensure that portable appliances are tested annually and that fire drills are conducted at least every six months to ensure the safety of the people who live at Abbingdon.Abbingdon HouseDS0000018851.V378183.R01.S.doc Version 5.2 A number of good practice recommendations are included in this report. Key inspection report CARE HOMES FOR OLDER PEOPLE Abbingdon House Abbingdon House 43 Thornton Road Bebington Wirral CH63 5PR Lead Inspector Mr Paul Kenyon Key Unannounced Inspection 19th October 2009 10:00 DS0000018851.V378183.R01.S.do c Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people 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 mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Abbingdon House DS0000018851.V378183.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). 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 CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Abbingdon House DS0000018851.V378183.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbingdon House Address Abbingdon House 43 Thornton Road Bebington Wirral CH63 5PR 0151 608 6722 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) Fairway Care Homes Limited Barbara Rankin Care Home 14 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (14) of places Abbingdon House DS0000018851.V378183.R01.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 category: Mental Disorder, excluding learning disability or dementia - Code MD The maximum number of service users who can be accommodated is: 14 Date of last inspection 28th August 2008 Brief Description of the Service: Abbingdon House is a residential home providing care and support to fourteen people. From the outside Abbingdon is not dissimilar from any other house in the residential street. The service is registered to provide support for individuals with a mental health need that is due to an age related condition. Outside space for individuals consists of a garden to the front of the home and a patio area to the rear. A large proportion of the rear garden is used to provide off-road parking. Accommodation is provided on two floors with access to the first floor through stairs or a passenger lift. There are five double bedrooms and four single bedrooms; the majority of rooms therefore provide shared accommodation. Downstairs there is a large lounge/dining area and a separate small smoking room. Toilets and bathrooms are provided on both the ground and first floors. Fees charged are at £389.69 but costs may be added for any additional levels of support required or additional items such as newspapers. The home is located in the Bebington area of Wirral and is close to local shops, post office and pubs and is a short bus ride from Birkenhead town. Abbingdon House DS0000018851.V378183.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 2 stars. This means the people who use this service experience Good quality outcomes. This was a key inspection of Abbingdon House and was unannounced. The visit took place during the morning and into the afternoon and took about six hours. During this time we looked at records relating to the care provided to the people living there and toured the building. We also spoke with staff and three people who use the service. We also had the opportunity to talk with a relative who was visiting during our visit. Any comments made are included within this report. The Deputy Manager and Owner of the service were present during our visit. The service sent its Annual Quality Assurance Assessment before the visit and when we asked them to. This provided information which assisted us in our visit and which we have used in the writing of this report. What the service does well: The procedure for obtaining assessments information for people who may come to live at Abbingdon assists in meeting the needs of people. The people who use the service have their needs met by the way the service devises and reviews care plans. Their health is maintained with the support of health professionals and by the way medication is managed. People have their privacy respected by the staff team. The people who use the service are able to pursue their daily routines and maintain links with their family and the community. People are encouraged to be as independent as possible. The meals provided at the service meet the nutritional needs of people as well as their preferences. The people who use the service have the information they need on how to raise any concerns they have about the support they receive. People are protected by the service’s policies, procedures and training provided to staff. The people who use the service live in a home like environment which is hygienic. Abbingdon House DS0000018851.V378183.R01.S.doc Version 5.2 Page 6 The people who use the service are supported by staff that are in sufficient numbers to meet their needs, are qualified and trained to meet their needs. The recruitment process protects individuals. People receive support from a well managed service that takes their views into account. Their financial interests are safeguarded by the service. Comments made during the visit included: ‘I am feeling fine but if I am not well they will get a Doctor’ ‘They look after me’ ‘I get out and about and can see my friends form the local church every week’ ‘The meals are fine and you can order alternatives if you do not like what’s on offer’ ‘I can keep in touch with my family’ ‘It is alright I love it here’ ‘I like my room’ ‘I have no complaints but if I did I would see the Manager’ ‘Staff are lovely, they help me’ ‘Staff listen to us’ ‘I have always been an early riser and staff let me do what I want’ ‘I get my privacy’ ‘We are treated with respect here’ ‘We are happy with this place-staff are good and they have done well with my relative’ ‘Staff are wonderful and they always let us know if things happen’ ‘My relative is well looked after and the place has been of benefit to them’ What has improved since the last inspection? What they could do better: The service must ensure that portable appliances are tested annually and that fire drills are conducted at least every six months to ensure the safety of the people who live at Abbingdon. Abbingdon House DS0000018851.V378183.R01.S.doc Version 5.2 Page 7 A number of good practice recommendations are included in this report. 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 on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Abbingdon House DS0000018851.V378183.R01.S.doc Version 5.3 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 Abbingdon House DS0000018851.V378183.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 2 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. No one has been admitted to Abbingdon since our last visit and as a result we are unable to determine whether the assessment procedure meets the needs of people. We could however determine that the admission process in theory provides the opportunity for people to visit the home and have their needs assessed so that they can be catered for at Abbingdon. EVIDENCE: We looked at how the service assesses the needs of people who come to live at Abbingdon. There had been no new admissions into the service since our last visit. There are currently has thirteen people living there with one vacancy. We were given a verbal account of how a new individual would be admitted. This would include assessments being done by the service as well as the obtaining Abbingdon House DS0000018851.V378183.R01.S.doc Version 5.3 Page 10 of local authority assessments. There would be the opportunity for the person to have trial stays at the service to assess their own wishes. The statement of purpose has now been updated following a recommendation at our last visit. This was reviewed in 2009 and is to be further reviewed in 2010. A further recommendation at our last visit was in respect of contracts of residency. The service has now devised contracts following discussions with the Authority that pays for people’s care. The Owner produced copies of the contracts for us and these will be signed by the people who use the service. Abbingdon House DS0000018851.V378183.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 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 this service. The people who use the service have their needs met by the way the service devises and reviews care plans. Their health is maintained with the support of health professionals and by the way medication is managed. People have their privacy respected by the staff team. EVIDENCE: We looked at four care relating to people who live at Abbingdon. In all cases, the care plan included clear information about how each person should be supported by the staff team. Each care plan provided details of the support needed with issues that were unique to each of the people. The care plans had been reviewed on a monthly basis and included details of the progress made for each person with each of their needs. Only one person had signed the care plan to confirm that they agreed with the contents of it and it is recommended Abbingdon House DS0000018851.V378183.R01.S.doc Version 5.3 Page 12 that this is extended to all people and their families so that they are more involved with the care that they receive. Care plans included details of the person’s religion and the preferred name they wished to be addressed by. We looked at how the service maintains the health of people. We interviewed three people about their health. In all cases they confirmed that they were well but when they needed assistance from a Doctor, this was provided. There was evidence of ongoing hospital appointments for some people as well as health support from Psychiatrists and Community Psychiatric Nurses. There was evidence that the influenza vaccination had been provided to people. Records confirmed that the service had sought to maintain both the physical and mental health of individuals. The service monitors the weights of people but this was more frequent for some individuals than others. It is recommended that the weights are monitored on a more consistent basis. We looked at the way the service promotes the health of people through the management of medication. No one self medicates at present and risk assessments are in place to reflect this. Risk assessments are also in place to outline the implications of when medication is not taken. There was evidence of support from Community Nurse in respect of monthly injections. There was evidence that Doctors had signed forms outlining what homely remedies people could safely have. We looked at medication records. These had been signed appropriately by the staff team. All received medication has been recorded and any medications returned to the pharmacy are also recorded. There are no controlled medications prescribed at present but there is storage available if needed. Injection medication used by Community Nurses is stored separately. Training records confirmed that staff had been on medication awareness and this was further confirmed through staff interviews. The Pharmacy provides training annually and checks periodically to ensure compliance with medication regulations. Medications are stored in a portable trolley that is locked when not in use and stored in main office We looked at how the service promotes the privacy of people. Interviews with three people confirmed that they all have their privacy respected and that staff treated them in a respectful manner. The building has a number of shared rooms. We viewed these and noted that screening was in place to ensure that there was privacy between the occupants of these rooms. There was evidence in risk assessments that the risks associated with offering keys to bedrooms had been taken into account. We observed that mail received by the service addressed to individuals remains unopened until the mail can be passed on to the person. We noted that one person had received mail that they opened and were requesting Abbingdon House DS0000018851.V378183.R01.S.doc Version 5.3 Page 13 advice from staff. The emphasis for staff with this was on staff providing advice only if the individual wished them to be involved. Abbingdon House DS0000018851.V378183.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 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 this service. The people who use the service are able to pursue their daily routines and maintain links with their family and the community. People are encouraged to be as independent as possible. The meals provided at the service meet the nutritional needs of people as well as their preferences. EVIDENCE: We interviewed three people. All confirmed that they were able to get up when they wanted and go to bed when they wanted. Activities are in place but individuals tend to pursue their own activities and this involves in-house activities as well as going out into the community themselves. People are able to maintain contact with the local community as well as their families and friends. Interviews with people confirmed that they were able to maintain links with their families who came to visit on a regular basis. Other people confirmed that they were able to maintain links with local interest group that they had been involved with for some time, for example, local churches. We Abbingdon House DS0000018851.V378183.R01.S.doc Version 5.3 Page 15 noted that those people who are going out into the local community would provide staff with an indication of when they would return. Other people are supported by staff to access the community. We had discussions with one relative who was able to confirm that they were able to visit whenever they wanted. We looked at the way people are able to maintain their independence. Interviews with people confirmed that they were able to deal with their own finances or had representatives who could provide assistance. The service is not involved with people’s finances but do provide a place for the safekeeping of monies. One person uses an advocate service which is linked to the Local Authority. No other people use advocacy services but there is information for people with contact details of local advocacy services on display in the building. People confirmed that they are independent from a mobility point of view in the building and in getting out and about although risk assessments are in place to ensure that the risks faced by people with this independence is taken into account. Care plans indicated that for some people there is no need for direct physical assistance from staff rather an emphasis on prompting and encouraging people with daily tasks. A tour of premises noted that bedrooms contain personal items such as furniture and personal possessions, photographs and items reflecting personal interests and hobbies. We looked at how food is provided to people who live at Abbingdon. Care plans indicated that there is an emphasis on healthy eating rather than any specialist diets being required by people. Care plans also indicated balanced diets and for one person a need to monitor the nutritional needs of that person. One person is a vegetarian through choice. Menus cover a four week period. Records and interviews with people confirmed that there is an alternative in place. Interviews considered that people are satisfied with the meals provided. The daily menu is on display in the building. A cook is employed and this person has current food hygiene certificate. A dining room is available with seating available for all. The kitchen is domestic in scale, clean and well organised. An environmental heath report for 2009 was available and this confirmed that there were no hygiene issues that needed to be addressed in the kitchen. Food stocks are sufficient and hot drinks are available through the day. Abbingdon House DS0000018851.V378183.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 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 this service. The people who use the service have the information they need on how to raise any concerns they have about the support they receive. People are protected by the service’s policies, procedures and training provided to staff. EVIDENCE: We looked at how people can express concerns they may have about the service they receive. The service has its own complaints records. No complaints had been made since our last visit and no complaints had been made to us about the service. A complaints procedure is on display in the main hallway. This includes the action the service will take in the event of a complaint being made as well as details of contacting us. Interviews with three people confirmed that they would go to the Manager if they had any concerns but had none at present. An interview with a relative also confirmed that they had no concerns. Abbingdon House DS0000018851.V378183.R01.S.doc Version 5.3 Page 17 In respect of safeguarding adults, the service has a copy of the Local Authority procedure and its own procedure in dealing with abuse allegations. Policies and procedures are in place in respect of whistle blowing. A staff interview confirmed their knowledge of the whistle blowing procedure and their receipt of safeguarding adults training. More safeguarding awareness training has been arranged for the next few months and staff have been identified to attend this. Physical and verbal aggression is a feature of some individuals living at Abbingdon. Care plans have identified this and include the action needed by staff to address this when it occurs. This is reinforced by risk assessments identifying and addressing the same issues. No allegations of abuse have been referred by the service since our last visit in 2008. Abbingdon House DS0000018851.V378183.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 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 this service. The people who use the service live in a home like environment which is hygienic. EVIDENCE: We toured the premises. The building is secure at the front and rear of the building. Maintenance staff are on duty during the day and a reapirs book indicates those routine repairs that need to be done. The building appeared to be in a good state of decoration and repair during our visit. A garden area is available to the rear of the building. This is accessible for all, is not overlooked and receives sunlight in finer weather. The external decoration of the building Abbingdon House DS0000018851.V378183.R01.S.doc Version 5.3 Page 19 is satisfactory. An environmental health report for 2009 was available and identified no issues. A fire risk assessment is in place for the service. People with mobility issues are able to access the upper floor of the building via a passenger lift which works satisfactorily. All areas of the building appeared clean and hygienic during our visit. There were no offensive odours present and there were towels and soap in all hand wash areas such as bathrooms and toilets. Domestic staff are employed by the service and were noted to be cleaning the building throughout the visit. A laundry area is available which is separate from food storage and preparation areas. Industrial appliances are used in this area and the laundry is an organised facility which is locked when not in use Abbingdon House DS0000018851.V378183.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 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 this service. The people who use the service are supported by staff that are in sufficient numbers to meet their needs, are qualified and trained to meet their needs. The recruitment process protects individuals. EVIDENCE: We looked at staffing levels in the service. A rota is available and includes the designation of staff. Generally two members of care staff are available for duty along with ancillary staff such as catering, maintenance and domestic staff. The Deputy Manager stated that extra staff are brought in when needed. Interviews with people confirmed that they considered staff to be ‘lovely, they look after me, are helpful and alright’ We looked at the qualifications of staff who worked at the service. An interview with two staff members confirmed that they had both attained at least a National Vocational Qualification (NVQ) at Level 3. This was reinforced by certificates that had been put on display in the building. Evidence suggested that more than 50 of staff had attained at least NVQ Level 2 and that some had progressed to Level 3. This standard is exceeded. Abbingdon House DS0000018851.V378183.R01.S.doc Version 5.3 Page 21 We looked at one personnel file relating to a person who had come to work at Abbingdon since our last visit. This file contained evidence that the service had made checks on the suitability of this person to perform this role. Checks included references, police checks and checks made against the protection of vulnerable adults register In respect of training, a staff interview confirmed that this person had received training in medication, had obtained a National Vocational Qualification at Level 3, Health and safety training, a food hygiene certificate and training in mental health awareness. Training records for other staff confirmed training in NVQ, Manual handling, food hygiene, mental health, fire training, first aid and infection control. The staff interview confirmed training had been received in safeguarding adults and there was evidence that other people were due to receive this training later in the year. Some training records had not been updated and did not reflect the certificates that had been obtained by staff more recently. It is recommended that these are updated. Abbingdon House DS0000018851.V378183.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 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 this service. People receive support from a well managed service that takes their views into account. Their financial interests are safeguarded by the service although their health and safety is not fully promoted by the service. EVIDENCE: The Manager has been registered with us for some time and has the experience to perform the role. She has attained a National Vocational Qualification at Level 4 and has the Registered Managers Award as confirmed Abbingdon House DS0000018851.V378183.R01.S.doc Version 5.3 Page 23 through a certificate on display. The Manager was not present during the visit but the deputy manager was present and was able to assist with the visit. A staff interview confirmed that the Manager was ‘approachable and supportive’ We looked at how the service checks the quality of the care it provides. Interviews with three people who use the service confirmed that their views are taken into account through a questionnaire. Some questionnaires were viewed and these had been completed in 2009 and signed by either the individual or their representatives. Comments were positive about the service. The Owner of the service was present for some of the visit. It is understood that he visits the service regularly but does not always complete evidence that the visits have taken place. It is recommended that these visits are more formalised. Both the deputy manager and staff were able to confirm that the owner visits regularly through the week. We were given access to all the records we needed, were able to interview staff and people in private and were able to gain access to all areas of the building. Requirements from last visit have been addressed. There was evidence that people’s finances are either dealt by their representatives such as families or solicitors or deal with their own monies. The service is not involved with people’s finances but have a role in storing money for safekeeping. We observed people using this service. Records are maintained, monies are individually stored and receipts retained resulting in an accountable and secure system. We were able to check records against two people’s accounts and found that they tallied. Staff training records confirmed that training takes place in health and safety topics. A system for the removing of clinical waste is in place. Certificates are in place to confirm the safety of electrical wiring and gas systems. Fire alarms and emergency lighting are tested regularly. Records suggested that fire drills are not as frequent as they should and this is raised as a requirement in this report. The passenger lift has been serviced recently and water temperatures are monitored. The service has information in relation to the control of substances hazardous to health and accidents are recorded. A fire risk assessment is in place. There was no evidence that portable appliances had been tested. This is raised as a requirement in this report. Abbingdon House DS0000018851.V378183.R01.S.doc Version 5.3 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 3 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X 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 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Abbingdon House DS0000018851.V378183.R01.S.doc Version 5.3 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 OP38 Regulation 23 Requirement Fire Drills must be held at least every six months so that the health and safety of the people who use the service is promoted. Portable appliances must be tested annually to ensure the health and safety of people is promoted. Timescale for action 30/11/09 2 OP38 23 30/11/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard OP7 OP8 OP30 OP33 Good Practice Recommendations The people who use the service or their families should sign care plans to confirm that they agree with the manner in which they are supported People’s weight should be more consistently monitored Training records should be updated to ensure that training received by staff is fully evidenced Reports relating to visits undertaken by the Owner commenting on the support provided by the service should be more formalised. Abbingdon House DS0000018851.V378183.R01.S.doc Version 5.3 Page 26 Care Quality Commission North West Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.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) Care Quality Commission (CQC). 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