Care Home: Abbotsford

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What the care home does well A very pleasant, ordered, traditional care home service is provided. What is striking are the very good relations that exist between the owners, the staff and residents. The owners have been running the home for 40 years and many of the staff have worked there for over ten years, some over 20 years. An excellent relationship has developed. Many of the staff referred to the owners as being, "very good, very friendly employers who listen to you if you have problems." Others that, "they are good employers. I`ve enjoyed it". This support for staff and pleasant way of carrying out business has resulted in very good loyalty on both sides with residents benefiting as a result. A culture of caring and working hard has developed. Residents in turn praised the staff and their work. One resident referred to the home as, "good and well run". The family owners take an approach which aims to provide residents with a service which they are used to and that they like. For example, an excellent environment has been created which is homely, attractive and well maintained. Residents have the freedom to follow their own interests and maintain contact with family, friends and the local community. There is an excellent track record of caring management at this home. The owners are considerate of the needs of residents and staff. They have been able to get the best from staff at the same time as providing a pleasant, well run home for residents. What has improved since the last inspection? The manager and staff have worked hard to improve the medication arrangements. This work has been successful. There have also been improvements to the physical standards with a new level access shower room installed on the ground floor. Further improvements to the premises are planned. The manager has reviewed the service when compiling the AQAA return. Various improvements to the service have been noted such as employing an activities provider to visit the home weekly and providing staff with more NVQ training. What the care home could do better: There is a need for a tightening up of reference requests when recruiting staff. Not all staff had two written references. Staff supervision needs to be formalised with supervision sessions recorded. The home`s quality assurance initiatives also need to be extended so that the feedback that is received is captured. There has been a great deal of verbal feedback, for example, which can be lost if not passed through a quality assurance process. The home`s safeguarding adults policy and procedure needs a review to make sure that it is compatible with the local authority safeguarding policy. In addition, staff would benefit from receiving local authority safeguarding adults training if that is available. Mental Capacity Act training should be included in this. CARE HOMES FOR OLDER PEOPLE Abbotsford 53 Moss Lane Pinner Middlesex HA5 3AZ Lead Inspector Duncan Paterson Key Unannounced Inspection 18th November 2008 10:00 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 Abbotsford DS0000017515.V373458.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. Abbotsford DS0000017515.V373458.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbotsford Address 53 Moss Lane Pinner Middlesex HA5 3AZ 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) 020 8866 6030 020 8426 2257 info@mosslanecare.co.uk Mrs J Spanswick-Smith Mr Derek Spanswick-Smith Mrs J Spanswick-Smith Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places Abbotsford DS0000017515.V373458.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Old age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is: 24 5th February 2008 Date of last inspection Brief Description of the Service: Abbotsford is a care home providing personal care and accommodation for up to 24 older people. There were 23 people living at the home at the time of the inspection but two of these were in hospital. The home is a family-run business, having been established by the owners in the 1960’s. Mrs Spanswick-Smith, one of the owners, manages the home. The family own a similar care home, Glengariff at 59 Moss Lane. People with lower dependency care needs are accommodated in Abbotsford. The home is situated in a quiet residential area of Pinner, fifteen minutes’ walk from local shops and public transport links. The forecourt has parking for a maximum of eight cars. The building has a ground and a first floor. Access is by passenger lift or stairs. All bedrooms are fully furnished, with some on the ground floor. The home has three communal bathrooms, one of which has facilities to support with getting in and out of the bath. There are other individual toilets available. The home has a large lounge that is split into a number of interconnected areas, one of which doubles as the dining area. The home also has a goodsized and well-maintained garden. References to the manager in this report refer to Mrs Karen Spanswick-Smith, the daughter of the registered manager, who oversees most aspects of day-toAbbotsford DS0000017515.V373458.R01.S.doc Version 5.2 Page 5 day management at this home. She is also registered as the manager of the sister home at Glengariff. The fee range for this home was £525 - £575 at the time of the inspection. Abbotsford DS0000017515.V373458.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 3 star. This means the people who use this service experience excellent quality outcomes. This key inspection took place on 18 November 2008. The inspection involved time at the home talking with residents, staff, relatives, visiting professionals and the manager. A standard form, the Annual Quality Assurance Assessment (AQAA), was returned to CSCI by the manager. This was taken into consideration. Three resident’s care arrangements were looked at in detail to assess care planning. The inspection also involved the assessment of a range of the home’s records, procedures and forms as well as observation and a tour of the premises. What the service does well: A very pleasant, ordered, traditional care home service is provided. What is striking are the very good relations that exist between the owners, the staff and residents. The owners have been running the home for 40 years and many of the staff have worked there for over ten years, some over 20 years. An excellent relationship has developed. Many of the staff referred to the owners as being, “very good, very friendly employers who listen to you if you have problems.” Others that, “they are good employers. I’ve enjoyed it”. This support for staff and pleasant way of carrying out business has resulted in very good loyalty on both sides with residents benefiting as a result. A culture of caring and working hard has developed. Residents in turn praised the staff and their work. One resident referred to the home as, “good and well run”. The family owners take an approach which aims to provide residents with a service which they are used to and that they like. For example, an excellent environment has been created which is homely, attractive and well maintained. Residents have the freedom to follow their own interests and maintain contact with family, friends and the local community. There is an excellent track record of caring management at this home. The owners are considerate of the needs of residents and staff. They have been able to get the best from staff at the same time as providing a pleasant, well run home for residents. Abbotsford DS0000017515.V373458.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? 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. Abbotsford DS0000017515.V373458.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 Abbotsford DS0000017515.V373458.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): 134&5 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The assessment process is detailed. Residents are given lots of opportunities to become familiar with the home before moving in and the manager and staff are careful to make sure they can provide the care that people need. There is a good range of information available about the home. EVIDENCE: There is a statement of purpose as well as brochure which are on display at the home. Many of the residents are from the local area and may have known people previously at the home. The manager advised that respite care is also offered so some residents are already familiar with the home before they move in. The home’s AQAA set out a process of offering new residents a trial of one month and of a day spent at the home before moving in. Three resident’s care plans and assessments were inspected as part of the case tracking process. One of these was a person who had recently moved to the home. Currently, all residents are private with no referrals from local Abbotsford DS0000017515.V373458.R01.S.doc Version 5.2 Page 10 authorities. Therefore, the assessment information has been entirely compiled by the home. There was relatively detailed paperwork relating to admissions. There was a standard admission form, which provided the required information about assessed need including a medical history, continence care, hearing needs and mobility. In addition, there were a range of assessments including a Waterlow assessment, a falls risk assessment and a manual handling assessment. All this added up to a great deal of information about each person which could then be transferred to the care plans. Discussions were held with the manager about the admission arrangements. She advised that the family own two care homes next door to each other. The other home provides care for people with a higher level of need. For Abbotsford, the aim is to admit people who have fewer physical and mental care needs than the sister home. Staff described only three to four residents as needing help with getting up and dressing. In addition, it was clear through observation and discussion with residents, that residents wished to do as much as possible for themselves. The profile at this home is therefore, of residents with a lower range of needs with less assistance needed with mobility. There is no mobile hoist for example, although there are assisted baths and there is a new level access shower room. This does mean that should residents needs increase it may not be possible for them to remain at this home. However, some residents have transferred to the next door home so that there can be consistency in care provision. Staff tend to work in both care homes and know all the residents well. Very positive feedback was received about the care provided and meeting people’s needs. The majority of the residents were spoken with and without exception they praised the care provided and the staff. They provided favourable comments about the staff and the service. One resident said that, “the staff are very good”. Another that staff, “do help very much. They will do anything I ask”. Two visiting relatives were spoken with. Both provided positive feedback about the service. One felt that their relative had been able to, “enjoy himself socialising with the other residents.” Abbotsford DS0000017515.V373458.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 & 10 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Care plans set out clearly how staff will assist with meeting residents’ needs. There are good links with health care professionals and there has been an improvement in the medication arrangements. EVIDENCE: The care planning documentation seen was detailed with typically a nine point care plan backed up by additional information and assessments. The additional material contained information about residents’ needs including records of health care appointments and specialist assessments. There were Waterlow pressure area care assessments on all care plans seen as well as manual handling assessments. There was also a section containing care notes for each person. A visiting district nurse was spoken with. She said that she visited the home weekly to do dressings for four residents. Currently, she did not treat anyone for a pressure sore. She felt that communication was good with the home and had no trouble carrying out her work. Abbotsford DS0000017515.V373458.R01.S.doc Version 5.2 Page 12 The medication storage arrangements and administration records were inspected. This had been an issue at the last key inspection and had been checked at a follow up visit in February 2008. Action had been taken at the time to comply with requirements given. The arrangements were good with assessments in place for those people self-administering medication, for example. One important feature of the home’s system was that of a weekly drug count. Paperwork was seen which confirmed that the receipt in of medication each week was being accounted for. The Nomad system was used which involves weekly receipt of medication. Currently, no controlled drugs are prescribed. The medication returns book was seen which provided evidence of the safe return of unused medication to the pharmacy. The manager advised that there are five to six GPs providing a service to residents. Often residents can retain their GP when they move to the home. The manager said that they were receiving a good service from GPs and that medication was being regularly reviewed. The manager and staff were observed to interact with residents in a courteous, friendly way. In some respects the atmosphere is a little formal but this does allow privacy to be offered and maintained for residents. The majority of residents are able to choose how to spend their time and this involves a variety of time in their bedrooms, sitting in the lounge or spending time with others. There was a small group of residents chatting together, for example, in the morning enjoying fresh air in the garden’s summerhouse. Abbotsford DS0000017515.V373458.R01.S.doc Version 5.2 Page 13 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): 12-15 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The manager and staff have been successful in providing an environment for residents which is familiar to them. Contact with relatives and the community is encouraged and residents are given the freedom to decide how they wish to spend their time. A range of activities is provided within a tranquil setting. EVIDENCE: There is a comfortable, well furnished, carefully laid out main communal room which is the centrepiece of the home. Residents can chose to spend their day here. On the evidence of this inspection around half of the residents spent their time in the lounge and the remainder in their bedrooms. There were a number of visitors throughout the day. A calm, relaxed, friendly atmosphere has been created. The manager, via the returned AQAA, stated that one of the aims of the service was to provide a life at the home for people which was similar to the one they would have had in their own homes. Many of the residents had lived nearby before moving to the home and there was encouragement for them to retain their interests, to have visitors and to decide how best to spend their time. On the evidence of this inspection the manager and staff have been successful in achieving this aim. Abbotsford DS0000017515.V373458.R01.S.doc Version 5.2 Page 14 The communal room is made up of interconnected lounge areas and a large rear extension to the home. There is space for dining, relaxing, meeting with others and smaller space for quiet sitting and for watching television. There is also space for dining. The area is in fact one large room but has been compartmentalised so that a number of activities can be carried out simultaneously without intrusion. There is also a large garden to the rear of the home which, even on a November day, was being used by residents either to sit out in a sheltered summerhouse or to take exercise. Residents confirmed that there were activities such as staff providing nail care as well as an activities lady who came weekly as well as quizzes and a Friday afternoon crafts session. A couple of residents spoken with wanted more activities, especially music. They felt the home could sometimes be “dull” and they felt music would liven things up. This was discussed with the manager who advised that they tried a number of things with residents and an activities provider had recently been employed to add to the service. The manager said that they worked with relatives and helped people go out of the home or receive visitors as much as possible. The serving of lunch was observed. The dining area was laid out in rows of single tables which at first seems rather formal. The manager advised that this is something they have always done and that tables would be brought together if residents wanted to sit with friends. Residents seemed to enjoy the meal. Staff served the meal efficiently and clearly knew residents and their food tastes and needs well. Staff described resident’s dietary requirements. This was relatively straightforward with staff aware of religious and diabetic diets. The meal looked appetising. One resident said that she liked the food and felt that, “the regularity” of meals was good. Other residents said that they liked the food. There had been a recent local authority inspection of the kitchen with the home awarded three stars. Abbotsford DS0000017515.V373458.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents can be confident that any complaints they make will be responded to sympathetically and investigated thoroughly. The safeguarding arrangements are adequate but would be improved through a review of the policy and procedure and additional staff training. EVIDENCE: There is a relevant complaints policy and procedure which is available for residents and their relatives. No complaints had been made since the last key inspection. The manager advised that the management style was to engage with residents and relatives as much as possible and respond to matters raised. For example, a conversation with a resident recently had made the manager re-evaluate the way she worked. There is a proactive approach taken and this may be one reason why no formal complaints have been made recently. The safeguarding arrangements were discussed with the manager. There is a safeguarding policy and procedure which the manager has recently reviewed. She has updated the policy and obtained the local authority safeguarding so that they can be read in conjunction with it. The home’s policy and procedure must be compatible with the local authority one and a recommendation is given about this. Similarly, a recommendation is given about obtaining safeguarding training for staff from the local authority. This should be considered as such training may include up-to-date details about the Mental Abbotsford DS0000017515.V373458.R01.S.doc Version 5.2 Page 16 Capacity Act and forthcoming Deprivation of Liberty safeguards which are to be introduced in April 2009. Abbotsford DS0000017515.V373458.R01.S.doc Version 5.2 Page 17 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): 19-26 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The physical standards are very good. A comfortable, attractive, well presented home is provided. EVIDENCE: The premises were inspected with the manager and discussions were held with the member of the family who takes the lead for the environment. A very pleasant environment is provided for residents. The home has been operative for more than 40 years and over that time the building has been extended with new rooms added and parts of the building converted for use as a care home. This work continues. For example, since the last key inspection a ground floor bathroom has been converted into a level floor access shower room. Other, similar additions are planned. The overall effect is one harmonious whole. The additions, such as the new shower room, have enhanced the facilities for residents and at the same time Abbotsford DS0000017515.V373458.R01.S.doc Version 5.2 Page 18 the home retains many attractive features and remains a comfortable place to live. The large communal area, for example, is very pleasant as well as being multi-purpose. The bedrooms seen were also pleasant being both spacious and comfortably furnished. There was a variety of furnishings with residents encouraged to bring in their own furniture if desired. The home is clean and attractively laid out with some good quality decorations and furnishings. There is a passenger lift which makes the building accessible for those who may have mobility difficulties. Although, there are some steps on the first floor which would mean that not all bedrooms there are fully accessible. There are plans to install a second shower room which would enhance the facilities further. There is a large, attractive and well maintained garden to the rear of the home. There is a path which goes runs around the perimeter. The manager advised that there were plans to relay this path to provide a smoother surface for residents. Abbotsford DS0000017515.V373458.R01.S.doc Version 5.2 Page 19 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): 27-30 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The residents benefit from very good relations between the owners and staff. Staff feel supported and are in turn motivated to provide a good service for residents. Recruitment needs to be tightened up but there are good training opportunities provided for staff. EVIDENCE: A meeting was held with a group of staff as well as with some staff individually. Staff expressed great satisfaction with life working at the home. The common feeling was that the family running the home were very good employers who looked after their staff and were able to get the best out of them. So much so that a number of the staff had worked at the home for in excess of 20 years. “Nothing could be better”, one said. This loyalty on both sides, between the owners and staff, resulted in an excellent service being provided to residents. The very good staff – owners relationship seems to be the bedrock of the home. The recruitment records for four new staff were inspected. This revealed that there is a need to tighten up the staff recruitment process. Two of the staff only had one written reference rather than the required two. There was a verbal reference received but this is not sufficient. A requirement is given about this. Abbotsford DS0000017515.V373458.R01.S.doc Version 5.2 Page 20 The staff training records were examined. The records are organised well with evidence available for the training staff have completed as well as (where possible) certificates. The manager advised that 11 out of the 14 staff have completed NVQ training at level 2 or above. There is an external training organisation which the home uses. Evidence was seen of training certificates relating to training that had been provided. Staff confirmed that they had received relevant training. The manager advised that diabetes training has been requested from the district nursing service and guidelines have been made available to staff. There is a flexibility within the staff team as the staff are contracted to work in both homes run by the family. This seems to work well. Staff said they liked doing this and that they knew the residents in both homes. They said that they worked overtime, by choice, and were not expected to work extra hours if they did not wish to. Abbotsford DS0000017515.V373458.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31 32 33 36 37 & 38 People who use this service experience excellent outcomes in this area. This judgement has been made using available evidence including a visit to this service. The management approach is one of careful consideration, sensitivity and desire to provide a good quality service for people. As a result, the home is very well run and the service provided in the best interests of residents. The addition of some more formal systems of quality assurance and staff supervision will consolidate the already good work in these areas. EVIDENCE: There is a very good track record of management and care provision at this service. The business is family run with a number of members of the family having management or operational roles within the business. There is a joint office for the two services. Mrs Spanswick–Smith is the registered manager of this home although her daughter, Karen Spanswick-Smith, who is the Abbotsford DS0000017515.V373458.R01.S.doc Version 5.2 Page 22 registered manager at the sister home, takes the lead for managing both homes. Residents, relatives and staff all commented favourably on the management of the service. There is a wealth of experience of running a successful care home service within the family. Mrs Spanswick was spoken with during the inspection and she was able to outline her ethos and the way she has developed the service over the years. It is because of the track record of success that this standard has been judged as excellent. There are some matters which need to be attended to, such as extending staff supervision and quality assurance initiatives, but the service has shown that it is good at assessing progress, formulating plans to address issues and putting them into practice. The AQAA returned by the home provides a good example of that. The tone of the AQAA was one of careful consideration of how the service could adapt with plans set out as to how best to develop the service and meet the needs of residents. The evidence of this inspection is that the approach taken by the family owners, of consideration and sensitivity to residents and staff, was appreciated by residents and staff. It also resulted in good relations, happy staff and a good service being provided by staff to residents. The AQAA states that the home’s quality assurance initiatives have not developed as much as they would have liked. This seems to be at the more formal end involving surveys. The manager said that surveys have been carried out but there were few returns. However, what has been received is a great deal of informal praise, comment and recognition from visitors, relatives and other professionals. This has not been captured in a formal quality assurance response and a recommendation is given that ways to do this are explored. Successful in other settings, for example, are records of compliments which can add up over time to be a useful record of the home’s achievements. The manager also plans to link the home’s quality assurance initiatives with the annual completion of the AQAA. Staff supervision is an area that must be developed. The manager said that they provide informal supervision and they have carried out group supervision but records are not routinely kept. It can be difficult, especially where there are good staff relations, for formal staff supervision arrangements to be introduced. At this home there is no doubt that staff are well supported and motivated and that they receive a range of relevant training. There also exist lots of day-to-day opportunities for staff to speak with the manager if needed. However, a way must be found to introduce regular recorded staff supervision. Staff supervision is a useful way of supporting staff and having a built in mechanism for addressing carefully and sensitively practice issues. It was not possible to assess the arrangements made to look after residents’ money. The manager advised that most residents look after their own money Abbotsford DS0000017515.V373458.R01.S.doc Version 5.2 Page 23 and the home only provides a place of safety for money for small amounts of residents. The staff member who takes the lead in this area was not at the home that day. A recommendation is given that there are alternative arrangements in place so that residents can have access to money when the staff member is away. The health and safety, fire and certificates of maintenance of equipment and installations, such as the lift and electrical safety, were inspected. These were all in order with the manager providing evidence of compliance, where required, after the inspection. Abbotsford DS0000017515.V373458.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 3 X 3 3 4 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 3 X 2 2 3 3 Abbotsford DS0000017515.V373458.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 OP29 Regulation 19 Requirement Two written references must be obtained for staff before they are offered work at the home. This complies with legislation and provides evidence of staff identity and experience. Regular staff supervision must be provided and the sessions must be recorded. Providing regular staff supervision allows the space and time to support staff and address issues of care practice. Timescale for action 01/01/09 2 OP36 18 01/01/09 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 Refer to Standard OP18 Good Practice Recommendations The safeguarding policy and procedure should be reviewed so that it matches the local authority safeguarding DS0000017515.V373458.R01.S.doc Version 5.2 Page 26 Abbotsford 2 3 OP18 OP33 4 OP35 procedure. Consideration should be given to providing staff with local authority safeguarding training. Mental Capacity Act training should be included in this where possible. Consideration should be given to extending the quality assurance initiatives and introducing more formal methods of capturing feedback from residents, relatives and other stakeholders. Alternative residents’ money handling arrangements should be put in place so that residents can access their money at all times. Abbotsford DS0000017515.V373458.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Abbotsford DS0000017515.V373458.R01.S.doc Version 5.2 Page 28 - 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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