Care Home: Abbotsford

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What the care home does well What has improved since the last inspection? Abbotsford has addressed the requirements and most of the recommendations made at the last inspection of the service. The care plans have been developed taking into account individual preferences, routines and making sure people with dementia are encouraged to make decisions and maintain their independence. The management and storage of controlled (very strong) medicines has improved and is robust. New staff have been appointed since the last key inspection of the service. These include a new cook, carers and a volunteer to assist with activities arranged in the home. A number of activities, games and vision books have been purchased for the people who use the service. The introduction of the role of `shift leader` ensures there is a person in charge at all times. All staff are deployed with clear roles and responsibilities. Some staff have commenced the 12 week dementia training to improve their understanding and knowledge on dementia and how dementia can affect people. There has been some environmental improvements made to the home. These include the installation of additional fire detectors, emergency lighting, coded locks to the rear gates and some internal decoration. The comments we received from the people who use the service and the surveys received, included: "I have never seen my mother as happy as she it today" "The whole experience is better than expected" "I believe that my mother has been happier than I have seen her for the at least 2 years" "6 months ago we were told she wouldn`t make it, needed help with all her personal care and now look at her, she does her own personal care with some prompts and fully mobile" "I think the home and the service has improved since .... (Acting Manager) has taken over. She always talks, sorts out any problems with me over mum when asked. I also think the standard of the home has improved" "The manager is very positive, she guides us (staff) properly" Abbotsford DS0000040840.V377528.R01.S.doc Version 5.2 What the care home could do better: This was a positive key inspection of Abbotsford. The information received from the people who use the service, relatives, staff and our findings during the site visit demonstrated significant improvements have been made. The information people receive about the home must be updated to reflect the changes in the management. The care plans need to be improved to contain important information and to be person centred. The environmental issue with regards to odours must be addressed to ensure people continue to live in a pleasant environment that promotes their health, safety and well-being. We also made a number of `good practice` recommendations, which were discussed with the Acting Manager during the site visit that would benefit the people who use the service. This also includes a recommendation that consideration should be made to have a `registered manager` for Abbotsford. Key inspection report CARE HOMES FOR OLDER PEOPLE Abbotsford 443 Wellingborough Road Abington Northampton Northants NN1 4EZ Lead Inspector Ms Rajshree Mistry Key Unannounced Inspection 7th September 2009 09:40 DS0000040840.V377528.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. Abbotsford DS0000040840.V377528.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 Abbotsford DS0000040840.V377528.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbotsford Address 443 Wellingborough Road Abington Northampton Northants NN1 4EZ 01604 636729 01604 636729 abbotsfordcare@majproperties.co.uk 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) Msaada Care Limited Manager post vacant Care Home 18 Category(ies) of Dementia - over 65 years of age (18), Old age, registration, with number not falling within any other category (18) of places Abbotsford DS0000040840.V377528.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered persons 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 are within the following categories: Dementia over 65 years of age - Code DE(E). Old age, not falling within any other category - code OP. The maximum number of service users who can be accommodated is 18. 14th October 2008 2. Date of last inspection Brief Description of the Service: Abbotsford is a care home registered to accommodated up to 18 people over the age of 65 years who have dementia related conditions. Abbotsford is owned by ‘Msaada Care Limited’. Abbotsford is a large Victorian house situated in Abington, Northampton. It is located on a busy main road, opposite a large park. The town centre is two miles away and it is on the local bus route. There is car parking on the residential streets nearby. The accommodation is set over three floors. The majority of bedrooms are single rooms, and some have en-suite facilities. There are two lounges and a separate dining room. The Acting Manager provided us with the range of fees, starting at £381.53 to £475.00 per week. There are additional personal expenditures for private chiropody, hairdresser and personal toiletries. People considering using Abbotsford should contact the home directly to discuss individual needs and requirements. Full details for Abbotsford and any specific requirements can be obtained in the form of the ‘Statement of Purpose’ and the ‘Service User Guide’. The latest Inspection Report from the Care Quality Commission is available at the home or accessible via our website: www.cqc.org.uk Abbotsford DS0000040840.V377528.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 Abbotsford is ‘2 star’. This means the people who use the service experience ‘good’ quality outcomes. ‘We’ as it appears throughout this Inspection Report refers to the ‘Care Quality Commission’ (CQC). This key inspection started with the review of the last key inspection dated 14th October 2008. We looked at the information we had about the management of Abbotsford and the events that affects the well-being of the people who use the service. This includes any complaints or concerns we may have received. We received from the Acting Manager the completed Annual Quality Assurance Assessment (AQAA) document. This is the home’s self assessment of the standards within the home. We sent out 16 surveys to the people who use the service, which included relative’s surveys. We received 3 surveys from the people who use the service and 5 from relatives. The responses and comments received indicated that people were satisfied with the quality of care and support from the staff, services and the facilities provided. The responses indicated people had the opportunity to live the lifestyle of their choice, participate in social events and activities arranged by the home, including observing their religious beliefs and practice. The responses also indicated people were confident to complain and have had their concerns addressed quickly. The comments received are reflected in this Inspection Report and supports our findings. We sent out a health professional survey to the General Practitioner but this was not returned. We sent out 15 staff surveys, of which 4 were returned. The responses indicated staff recruitment was fair, staff receive supervision and training to meet the needs of people who use the service. The responses also indicated there is good information, records and communication systems in place to ensure people’s needs are met safely. The comments received are included throughout this Inspection Report and supports our findings. We visited Abbotsford on 7th September 2009, starting at 9:40am and lasted over 7 hours. The Acting Manager assisted us during the site visit. The main method of inspecting we used was ‘case tracking’. This means looking at the range of health and personal care people receive that is met by the staff at the home. We selected four people to case track, all having differing needs, level of independence, ability and included a person that was Abbotsford DS0000040840.V377528.R01.S.doc Version 5.2 Page 6 new to the service. We looked at how people’s rights, choice, dignity and independence, is promoted by the staff at the home. We spoke with those people and other people using the service. We read their care files containing information about their health and personal care needs, lifestyle and how these are met. We made observations of how people are treated and supported by the staff with regards to promoting and maintained their independence and well-being. We spoke with the staff at all levels, roles and responsibilities to ascertain the recruitment process, training, staff skills and the management of the home. We made observations of how staff treat the people who use the service and the deployment of staff to ensure needs are met. We looked at the staff files that demonstrated staff recruitment, training and the skill-mix of the staff. We looked at the accommodation offered to people who use the service. This included the communal areas, bathrooms and individual bedrooms. We read the information people receive about Abbotsford. We looked at how the policies and procedures are followed by the staff that ensures health and safety. We looked at the specific records that demonstrated the day-to-day management of the service and how people that use the service are informed and consulted about the quality of care they experience. The Care Quality Commission has a focus on ‘Equality and Diversity’ and issues relating to these are included throughout this Inspection Report. What the service does well: Abbotsford is an established care home. It is a large Victorian house set overlooking the park across the main road. All areas of the home are clean and tidy. There is a welcoming atmosphere in the home that is warm and relaxed. People who are considering using Abbotsford and their relatives are encouraged to visit the home. They are involved in the assessment process to find out what help they need. People are involved in developing their plan of care or have the support of their relatives or advocates. People’s routines are promoted and they are supported to take part in activities and social events arranged by the staff at the home. People are able to receive visitors at any time and also go out with family. All the meals are prepared at the home and people have a choice of meals offered to them. Abbotsford manages and addresses concerns and complaints quickly, in line with the complaints procedure. Abbotsford DS0000040840.V377528.R01.S.doc Version 5.2 Page 7 Staff recruitment and training is good. Staff receive regular training for their roles and responsibilities and have awareness training to support people who use the service. This includes training in ‘dementia’ and understanding how dementia affects people in different ways. Staff are caring and patient. Staff interact with the people showing respect and awareness of people’s needs, routines and abilities. People who use the service are consulted about the quality of service they experience at regular intervals. There are good internal monitoring systems and checks in place to ensure people’s health and safety. Some of the comments received in the surveys from the people who use the service, their relatives and staff and from our discussions on the day, included: “Looks after us. Anything we as for we get” “Keeps us clean and cared for” “You saw us having a laugh trying to exercise, I think we laugh and joke more than exercise” “They fulfil all that is required for my aged mother, maintaining good levels of all services” “Residents and staff are always smiling” “I call my daughter whenever I want and they come to see me here” “They are really patient and you just need to ask them” “Gives my mother the care and attention that has enabled her to experience a better quality of life than she had before” “If we are not happy we can talk to the manager – she always has a willing ear and cares, not afraid to say what you want” “Abbotsford is a happy friendly, relaxed environment to work and be in” “Abbotsford takes a keen interest in the residents’ well-being, there is a good relationship between residents and the staff and the management” “The home is like a big family” Abbotsford DS0000040840.V377528.R01.S.doc Version 5.2 Page 8 What has improved since the last inspection? Abbotsford has addressed the requirements and most of the recommendations made at the last inspection of the service. The care plans have been developed taking into account individual preferences, routines and making sure people with dementia are encouraged to make decisions and maintain their independence. The management and storage of controlled (very strong) medicines has improved and is robust. New staff have been appointed since the last key inspection of the service. These include a new cook, carers and a volunteer to assist with activities arranged in the home. A number of activities, games and vision books have been purchased for the people who use the service. The introduction of the role of ‘shift leader’ ensures there is a person in charge at all times. All staff are deployed with clear roles and responsibilities. Some staff have commenced the 12 week dementia training to improve their understanding and knowledge on dementia and how dementia can affect people. There has been some environmental improvements made to the home. These include the installation of additional fire detectors, emergency lighting, coded locks to the rear gates and some internal decoration. The comments we received from the people who use the service and the surveys received, included: “I have never seen my mother as happy as she it today” “The whole experience is better than expected” “I believe that my mother has been happier than I have seen her for the at least 2 years” “6 months ago we were told she wouldn’t make it, needed help with all her personal care and now look at her, she does her own personal care with some prompts and fully mobile” “I think the home and the service has improved since …. (Acting Manager) has taken over. She always talks, sorts out any problems with me over mum when asked. I also think the standard of the home has improved” “The manager is very positive, she guides us (staff) properly” Abbotsford DS0000040840.V377528.R01.S.doc Version 5.2 Page 9 What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details 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. Abbotsford DS0000040840.V377528.R01.S.doc Version 5.2 Page 10 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 DS0000040840.V377528.R01.S.doc Version 5.3 Page 11 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): 1, 3 and 5. Standard 6 is not applicable. 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 information about the home and are involved in the assessment process to ensure their needs will be met. EVIDENCE: We wanted to find out what information people receive about Abbotsford and people’s experience of moving into the home. The information we gathered from the self-assessment completed by the Acting Manager stated, ‘detailed information about the home is provided’, ‘assessed to ensure their needs can be met’ and ‘offer the opportunity to spend time with us’. This indicated there was a process whereby they are encouraged to visit the home to ensure Abbotsford is the right place for them. Abbotsford DS0000040840.V377528.R01.S.doc Version 5.3 Page 12 The Acting Manager was unable to provide us with the ‘Service User Guide’, for Abbotsford, which is given to people who are considering using the service. We read the ‘Statement of Purpose’. This tells people what they can expect from the service ranging from the how health, care and social needs would be met, the accommodation, choice of menus and the staffing. It also sets out the aims and objectives of the home, the key policies and procedures by which, the service operates and includes the complaints procedure. We discussed with the Acting Manager the need to update all the information people receive about Abbotsford, making sure it is reflective of the changes in management and is available in alternative formats to suit the needs of the people who use the service. The surveys responses received from the people who use the service and their relatives confirmed they and/or their relative made an informed decision about using the home. This was consistent with the comments we received from our discussions with several people who use the service including a new person who we case tracked. The comments received included: “The whole experience was better than I expected” “My daughter came and had a look around and said, dad, I think you’ll like it but you need to tell me if you don’t” “I moved here after my husband died and I wasn’t coping very well at home” The information we gathered from the self-assessment stated that people’s ‘needs are assessed’. This is a process by which individual care needs and preferences, routines and interests are made known. Some people that we spoke with said they were asked about the help they needed although some people were unable to remember. The newest person at the home that we case tracked said, “I was asked about what help I need and right now I look after myself”. This supported the responses received in the surveys from the people who use the service. We concluded people who use the service and their relatives, in some cases, are involved in the assessment process to ensure their needs are met. We read the care files for the people we case tracked. All had a copy of the home’s assessment of need, completed by the Acting Manager at the time. The assessments read showed good information was gathered about the person, their needs and the people involved in their well-being such as family and the General Practitioner (GP).Other information gathered related to their medical history and any diagnosis, medication, physical mobility, cognitive ability, diet and nutrition, communication, social interest, any known risk such as self-neglect, challenging behaviour or the use of special equipment and the reason for moving to Abbotsford. This showed that the assessment process is good, ensuring individual needs and risks were known and can be met by the staff at the home. Abbotsford DS0000040840.V377528.R01.S.doc Version 5.3 Page 13 The Acting Manger confirmed that they have not referred anyone to the local authority in line with the ‘Mental Capacity Act’ and the ‘Deprivation of Liberty’. This ‘act’, means a person that cannot make a decision for themselves or might be able to make some decisions and not others, which is called ‘lacking capacity’. They said they had received information about were aware that the assessment process needed to be updated. We wanted to find out what information staff receive about new people that move to the home. Staff we spoke with said they have good information made available to them in the care files, the care plans and handover meetings. Staff said they benefit from working in a small home with a stable staff team, where there is good communication between the staff. This was consisted with the responses received in the staff surveys, which included: “Manager does the assessments” “Information about the new person is in the care files, care plan and she tells us at the handover meetings” The information we gathered from the self-assessment completed by the Acting Manager stated ‘we provide a contract’. The Acting Manager confirmed people are given contracts with the terms and conditions of the stay, including people who are funded by the local authority. The newest person said told us their ‘daughter had done all the paperwork for me’. The care files we also saw copies of the assessment and individual agreements completed by the Care Management Team, which forms an agreement. We concluded from the evidence gathered from the self-assessment and our findings on the day that contracts and formals agreements are in place. Abbotsford does not provide intermediate care. Abbotsford DS0000040840.V377528.R01.S.doc Version 5.3 Page 14 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. People’s health and personal care needs are met by improving care plans and by trained staff who understand and promotes their independence and wellbeing. EVIDENCE: We wanted to find out how people’s health and personal care needs are met. The information we gathered from the self-assessment completed by the Acting Manager stated people, ‘are assisted with all their personal care needs if required and promoted independence’ and ‘care plans notes are updated as and when required’. The self-assessment also stated the support provided by the health care professionals such as the General Practitioner (GP) and District Nurse. This indicated that the service has systems and arrangements in place to meet people’s personal care and health needs. Abbotsford DS0000040840.V377528.R01.S.doc Version 5.3 Page 15 The responses and comments received in the surveys from the people who use the service and their relatives indicated they receive the care and support they need. This was consistent with the comments received from our discussions with the people who use the service and our observations of staff responding to people’s requests. The comments received included: “Looks after us. Anything we ask for we get” “Keeps us clean and cared for” “Someone always helps me with dressing, personal hygiene and walking – nothing is too much trouble” “They fulfil all that is required for my aged mother, maintaining good levels of all services” “Gives my mother the care and attention that has enabled her to experience a better quality of life than she had before” Some people we spoke, including the newest person told us they were involved in developing their ‘care plan’. This tells the staff what help people need with regards to personal care, preferences and their lifestyle. Whilst some people needed help from the staff, there were other people who benefited from being reminded or prompted by the staff. This demonstrated that people who use the service are supported to continue being as independent as far as possible. We read the care files: the care plans, daily records; assessments of risks and records that show the health care support people receive from the GP or the District Nurse. The care plans were individual and reflected their needs and the level of support they required. The care plan for the newest person was personalised, holistic, comprehensive and written from the view of the individual. This is called ‘person centred’. We identified a care plan where allergies were identified in the assessment but not reflected in the care plans or how the person was protected. We brought this to the attention of the Acting Manager, who was not aware of the information is the assessment. The Acting Manager gave us assurance they would check and ensure the care plans were accurate. They confirmed they plan to update all the care plans to the new format that provides good information and guidance to the staff to maintain and promote people’s rights, choices and independence. All the care files read had assessments of risk, relating to moving and handling, falls and specific risks relating to themselves and others such as selfneglect and challenging behaviours. All the care plans read reflected the safety measures identified from these risk assessments. This demonstrated people’s individual needs were known and information is provided for staff to help them provide the care people needed, which promotes their well-being and independence. Abbotsford DS0000040840.V377528.R01.S.doc Version 5.3 Page 16 Staff we spoke with said they are key-workers for individual people and are responsible for reviewing the care plans on a monthly basis or sooner if necessary. The care files read all contained evidence that reviews were taking place regularly and supported our findings. Staff demonstrated from our discussions that they know the people who use the service, their needs, routines, habits and what to do if the person becomes confused, upset or agitated. Staff said they were completing the ‘long distant dementia awareness course’ and demonstrated how dementia affects people. Staff described how they support some people and encourage them to maintain their independence whilst other people require minimal support or prompting. This showed staff do promote and encourage people to maintain their independence. Some of the comments received from the staff from our discussions and in the staff surveys included: “Promotes person centred holistic approach to care” “6 months ago we were told she wouldn’t make it, needed help with all her personal care and now look at her, she does her own personal care with some prompts and fully mobile” The daily records completed by the staff reflected the care and support needs provided and their well-being. Other records maintained included visits from the GP and the District Nurse. The people we spoke with said they see the GP when they need to and the newest person said: the nurse comes from the surgery and takes my blood regularly for testing”. This showed people were having their health care needs met. We did send out a survey to the General Practitioner to ascertain their view about the care provided to the people who use Abbotsford, but it was not returned. We wanted to know whether the management system for medicines was safe. The people who use the service told us they get the medicines on time and included these comments: “I always get my tablets on time; I take warfarin so I have to have regular blood tests” The staff on duty responsible for administering the medication described and showed us the medication system and storage. All medicines are kept in the locked medication trolley. The Acting Manager confirmed they and the staff in the role of ‘shift leaders’ are trained to administer medication and training records supported this. We observed two staff giving out medication and signing the medication record sheet individually. Individual medication records also had a photograph of the person, which serves a reminder who the medication is for. The ‘shift leader’ wore a notice to alert the people who use the service not to disturb them as Abbotsford DS0000040840.V377528.R01.S.doc Version 5.3 Page 17 they were administering medication. People who use the service respected this knowing it was an important task that needed to be done carefully. We concluded that the medication system and practice was good and the recording was good. The ‘controlled’ (very strong) medicines are kept in the locked in the secure controlled medication storage, which meets the Pharmaceutical Regulations. We checked the number of controlled medicines against the records for two people we case tracked, which require the signature of two staff. We concluded that the management, storage, administration and recording for controlled medicines was good. Throughout the site visit we observed we observed staff supporting people throughout the day. Staff were sensitive, responded to people using their preferred form of address and were patient allowing the person to finish what they were saying. We saw were vigilant and had conversations with people, which made them feel important and valued. People’s privacy and dignity is maintained when staff were helping them. Everyone who uses the service were well dressed and presented. We saw a number of ladies who use the service had their nails painted. They commented on the ‘staff taking time to paint our nails’. We concluded people who use the service were made to feel important, valued and their privacy, dignity and lifestyle is promoted. Abbotsford DS0000040840.V377528.R01.S.doc Version 5.3 Page 18 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. People maintain contact with family, experience their choice of lifestyle, take part in social activities and offered a choice of meals that promotes their wellbeing. EVIDENCE: We wanted to find out what social opportunities and activities are available to people who use the service. The information we gathered from self-assessment stated, ‘there are two outside entertainers that attend monthly, regular weekly hairdresser’, ‘the pat the dog’, ‘chiropodist visits’ and ‘a family member who holds hymn sessions’. It also stated they have purchased activities, games and vision books to benefit the people who use the service. The ‘statement of purpose’ also detailed some of the leisure opportunities made available to the people who use the service, demonstrating individual interests and hobbies are encouraged. Abbotsford DS0000040840.V377528.R01.S.doc Version 5.3 Page 19 The surveys responses and comments received from the people who use the service and their relatives indicated people have visitors and enjoy a quality of life that suits them. We also received from in these surveys and the staff surveys with some suggestions that we shared with the Acting Manager, which included: “The whole experience is better than I expected” “I believe that my mother has been happier than I have seen her for the at least 2 years” “It is a very friendly home, always smiling patients and very pleasant staff and atmosphere” “I have never seen my mother as happy as she it today” “Perhaps to provide more comfortable visiting areas” “…. and arrange vehicles to bring the residents in the park once in a month” Throughout the day we saw people moving around the home freely. People sat in one of the two lounges, watching the morning television, reading a magazine or talking. One person said they have the daily newspapers delivered, which they enjoy reading. The atmosphere was relaxed and welcoming. We saw a notice board in the dining room with the range of activities and events that take place. These ranged from the visits from the hairdresser, chiropodist visits by appointment, hymns, book reading to chair exercise, although there was no set programme of activities for the week or month displayed. The Acting Manager told us they had recruited a ‘volunteer worker’ to do activities but have yet to agree the start date and the hours. We saw two staff, one in each lounge, doing different activities mid morning. In the larger lounge, people were doing chair exercises. People appeared to be enjoying themselves as they laughed and joked with each other trying to do the exercises and follow the instructions read out by the member of staff. A member of staff told us they thought people would benefit from having a larger television in the large lounge and we suggested they tell the Acting Manager. We saw one lady sitting in the garden, as she enjoyed smoking the cigarette. She said “I like my own company and smoking out here”. Another lady liked to walk, talk about things and sang songs. This showed people enjoyed taking part in the activities, made choices about what they do and included comments such as: “I keep busy and chit-chat with the ladies” “You saw us having a laugh trying to exercise, I think we laugh and joke more that exercise” Abbotsford DS0000040840.V377528.R01.S.doc Version 5.3 Page 20 “There’s some entertainment but not like the place in ……, where I was before” “It would be nice to go out more but it can be difficult here” “I can’t sit quiet or still for too long before I ….” “I call my daughter whenever I want and they come to see me here” “I like to have a nap after lunch and usually disappear to my bedroom” We wanted to find out what information staff have about people’s interests and choice of lifestyle. Staff said the care files and the care plans have information about people’s interests and hobbies. We saw the ‘activity record’ completed for the people we case tracked, showing the range of things people had done. This included family and friends visiting them. Staff demonstrated by giving us examples of how they support some people with dementia to take part in activities of interest to them, saying, “you sometimes here her swearing as she’s singing and we gently remind her that she shouldn’t use those words and sing with her . . . . . knees up Charlie Brown….”. Another member of staff who was speaking to another lady said, “I go to church every Sunday, someone from the church fetches me”. We wanted to find out what the meals were like. There was not information in the self-assessment completed by the Acting Manager regarding the choice of meals offered. The care files had information about people’s preferences and dietary needs. We spoke with the cook, who is newly appointed to the home and was preparing lunch, saying “there is always a choice but they all enjoy ‘toad-in-the-hole”. They told us there were no special dietary needs although one person preferred to eat only roast potatoes everyday. We discussed with the Acting Manager what input people who use the service have to influence the menus and whether they have sought advice from the Dietician with regards to ensuring people have a healthy and balanced diet. They told us they have regular ‘residents’ meeting’, where the menu and choice of meals are discussed and have received information from the local authority with regards to nutritional menus. We also suggested that they consider developing menus in formats that would enable people with dementia to choose the meal that they would prefer, which was accepted by the Acting Manager. The surveys from the people who use the service and their relatives all indicated that people ‘like the meals offered’. People we spoke with before and after lunch all commented on enjoying the choice and variety of meals provided. The meals were served individually at the dining table or in the lounge for a few people. The meals were well presented and looked nutritious. We saw a member of staff assisting one person in the lounge with their meals, in a sensitive manner. We concluded that people enjoyed the meals offered and enjoyed the mealtime experience. Abbotsford DS0000040840.V377528.R01.S.doc Version 5.3 Page 21 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. People are confident to complain that are addressed quickly and are protected by trained staff that ensures their safety and protected from harm and abuse. EVIDENCE: We wanted to find out whether people were aware of the complaints procedure, confident to complain and felt safe and protected at Abbotsford. The information we gathered from the self-assessment completed by the Acting Manager stated, ‘we aim to respond to the matter raised quickly, effectively and honestly’ and ‘should a complaint not be resolved with the home’s manager, the matter would be referred to head office’. It also stated the home welcomes all comments, complaints and suggestions. The complaints procedure was displayed and is included in the ‘statement of purpose’, which is given to people when they move to the home. The complaints procedure is clear and includes the contact details for the head office of the company, the local authority and the Care Quality Commission (CQC). The surveys responses and comments received from the people who use the service and their relatives all indicated they know how to make a complaint Abbotsford DS0000040840.V377528.R01.S.doc Version 5.3 Page 22 and have had complaints addressed quickly. The people who use the service said they felt safe and were confident to complain directly or would speak with their relative first. This demonstrated that the service responds and acts in accordance with the complaints procedure. Some of the comments received included: “I think the home and the service has improved since ….. (Acting Manager) has taken over. She always talks, sorts out any problems with me over mum when asked” “Would tell ……(Acting Manager) or speak to my daughter” “There’s nothing to complain about” “If we are not happy we can talk to the manager – she always has a willing ear and cares, not afraid to say what you want” The information gathered from the self-assessment stated two complaints were received by the service. We read the complaints log, correspondence and actions taken. The Acting Manager demonstrated that they welcomed comments and concerns and endeavour to address them quickly, recognising the distress it could have on the person who lives at the home. We concluded that the complaints procedure was followed and all the complaints were resolved satisfactorily. The Care Quality Commission received no complaints about Abbotsford. We spoke with the Acting Manager with regards to the ‘Mental Capacity Act 2005’, who demonstrated what this ‘act’ meant for them as a care home. They confirmed they have received information about the ‘Deprivation of Liberty’s’ and had not referred any one who lives at the home, to the local authority. This means, a person cannot make a decision for themselves or might be able to make some decisions and not others, which is called ‘lacking capacity’. We had already discussed with the Acting Manager the need to review and update the assessment of needs to take into account people’s capacity to make decisions. The information gathered from the self-assessment stated there were 5 safeguarding referrals and investigations, since the last key inspection. We were notified of the safeguarding referrals, which were managed and investigated by the local authority. We wanted to find out if staff knew what ‘safeguarding issues’ issues meant and how to deal with any suspicions or allegations of abuse. ‘Safeguarding’ issues means promoting the well-being of people who use the service from harm, risk and abuse. Staff we spoke with demonstrated a good understanding of the various forms of abuse that could occur and were aware Abbotsford DS0000040840.V377528.R01.S.doc Version 5.3 Page 23 of their responsibilities to report concerns to the Acting Manager. Staff were confident to raise concerns with regards to poor care practices using the ‘whistle-blowing’ procedure. Staff confirmed they had received induction training that included training in the safeguarding procedures. Staff also demonstrated they work as a team, have good communication and have a desire to make sure people are safe and well-cared for. Some staff are completing ‘dementia awareness’ courses and demonstrated how dementia affects people differently. The responses and comments received in the staff surveys, supported our discussions with the staff and included the following comments: “The new staff are great, we all have different strengths and we all learn from each other. In fact, some of the younger staff are trained as OT’s and physio’s” “These people are vulnerable and we can help them so much to make sure they stay as independent as possible rather than sitting looking at the TV, as you see in some homes” “Some people have dementia and need some help from us even if it is to talk with them, give them reassurance, then they are fine” “We have good staff here I think” The staff records viewed, staff survey responses and from our discussion with the staff, all confirmed they were recruited upon receipt of satisfactory preemployment checks. These included two written references and a criminal records bureau check (crb). This is a check to assess the suitability of the applicant to work with vulnerable people. This demonstrated staff recruitment procedures are following to ensure people are cared for by suitable staff that promotes their safety and well-being. Abbotsford DS0000040840.V377528.R01.S.doc Version 5.3 Page 24 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, 20, 21, 24, 25 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. People live in a comfortable, clean and tidy home that promotes their health and well-being. EVIDENCE: We wanted to find out what type of home and accommodation people live in. The information gathered from the self-assessment completed by the Acting Manager stated they ‘provide a clean, safe and secure environment for people with dementia’ and ‘useful signage in designated areas’. We also received details of when the equipment such as hoists, heating, fire detections and electrical systems were last tested. The improvements made to the home included the extra fire detectors installed, emergency lighting, coded locks to the back gates, landscaped the front garden and updating some interior décor. Abbotsford DS0000040840.V377528.R01.S.doc Version 5.3 Page 25 The surveys responses and comments received from the people who use the service, their relatives and the staff indicated that people were generally happy with the home and the facilities. The comments received were positive with regards to the cleanliness and there were also suggestions, which we shared with the Acting Manager: “I think the home and the service has improved since …. (Acting Manager) has taken over. I also think the standard of the home has improved” “My daughter came and looked round and she thought I’d like this room” “Abbotsford is a happy, friendly and relaxed environment to work in” “Perhaps to provide more comfortable visiting areas” “Deals with fire risk assessments, all health and safety issues, etc” “Abbotsford could do with a few more improvements to the garden and interior decoration” “Sort out clients clothes in the wardrobes better” There is a scaffold erected to the front of the home. The Acting Manager said they were having the roof repaired following the recent storms. They confirmed that people’s health and safety has been maintained and they have not been affected by the scaffolding or the works being carried out. We spent time talking with some people in the lounge, individual bedrooms and in the dining room. People said they were happy with the layout of the home, cleanliness and could find their way around easily with the help of the notices on the bathroom and toilets. All areas of the home were clean and tidy. There was good lighting throughout the home. We noted that there were gates at the bottom and tops of the stairs. Staff told us this was put in place to avoid some people using the stairs who would be at risk of falling. However, other people were able to use the stairs or the passenger lift, without restriction. We looked around the home and in some bedrooms with a member of staff. All the bedrooms are located over three floors, accessible via the stairs or the passenger lift. There are four shared bedrooms, which have privacy screens. Some bedrooms have en-suite toilets, whilst others have bathrooms and toilet facilities close by. The bedrooms were individual in character, decorated, had a range of bedroom furniture and personalised with personal affects. We found one bedroom where there was a strong offensive odour and another bedroom where the beds had not been made properly by the temporary house-keeper. The member of staff brought this to the attention of the Acting Manager, displaying dissatisfaction with the way the beds were made. The Acting Abbotsford DS0000040840.V377528.R01.S.doc Version 5.3 Page 26 Manager accepted they need to address the offensive odour in the bedroom, as the smell appeared to have penetrated into the carpets. The laundry room is located away from the areas where food is prepared. People told us they were satisfied with the laundry arrangements, having their clothes returned to them. The staff said there is a house keeper who is responsible for keeping the home clean and tidy and staff on duty are responsible for the laundry. Some of the comments received from the people we spoke with included: “It’s not bad at all they clean my room, fetch my dirty washing and usually get it back the same day, all washed and ironed” “I manage with most things myself but they clean my bedroom and do the laundry” We observed staff wearing protecting clothing such as gloves and aprons, when administering medication, assisting with meals and preparing to assist people with their personal care needs. Staff spoken with demonstrated a good understanding of infection control practices and the measures taken to prevent cross infection. The staff training records showed staff receive regular training and updates in infection control, health and safety and food hygiene. We also read the ‘Infection Control’ report, from the visit carried out in January 2009. The home met the regulations and a recommendation was made with regards to provision of ‘foot operated pedal bins with lids’ in the bathrooms. We discussed with the Acting Manager whether any considerations were made with regards to making the home environment better for the people with dementia such as using plain or minimal patterned décor and floor covering. The Acting Manager said they have requested improvements to the interior decoration. We also suggested that they seek guidance from organisations that advocate and support people with dementia. Abbotsford DS0000040840.V377528.R01.S.doc Version 5.3 Page 27 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. People who live at the home are protected and supported by staff recruitment process and staff training that promotes their health, safety and well-being. EVIDENCE: We wanted to find out whether the staff recruitment process, the skill-mix and the staffing levels met the needs of the people who use the service. The information we gathered from the self assessment completed by the Acting Manager stated, ‘all staff have a new crb check and induction upon commencement of employment’, employ sufficient staff numbers’ and ‘offer staff training, regular supervision and appraisals’. There is a housekeeper, who is responsible for cleanliness of the home and a new cook. The improvements made include some staff who are studying a 12 week dementia course. The people who use the service spoke positively about the staff that work at the home. The comments received were consistent with the comments received in the surveys from the people who use the service and their relatives. These included: “Staff are always pleasant” Abbotsford DS0000040840.V377528.R01.S.doc Version 5.3 Page 28 “It is a very friendly home, always smiling patients and very pleasant staff and atmosphere” “The girls are very good” “They are really patient and you just need to ask them” “…… (Acting Manager) is good too, you always see her around and comes and talks to you” We observed staff talking with the people using the service in a polite and courteous manner. Staff were not phased by some people’s comments and reaction, partially due to their dementia. Staff spoke with people in a tone that was friendly and respectful, which supported the comments we received. We concluded that staff treat people with respect. We saw the staff rota displayed indicating the staffing levels, roles and allocated responsibilities. At present there are three staff working during the day, of which, one is a ‘shift leader’ who has the responsibility of administering the medication and assisting any visiting health care professional. The staff survey responses and comments received indicated people who use the service benefit from a stable staff team staff that understand the needs of people. This also promotes continuity of care. Staff spoken with described to us the recruitment process they experienced and told us about the pre-employments checks carried out. We looked at four staff files. All files contained evidence of the pre-employment checks carried out such as two satisfactory written references, criminal records bureau (crb) checks and a protection of vulnerable adults (pova) check. This is a check to assess the suitability of the applicant to work with vulnerable people. We found checks were also made on overseas staff although in one staff file it was unclear whether they had a current work permit. Although the Acting Manager confirmed the status of the staff over the telephone with the Human Resource Team, they should ensure staff records are kept up to date. We spoke with the Acting Manager to establish what role they have in staff recruitment. This would show the staff have the right skills, experience and qualities and would compliment the staff team and benefit the people who use the service. They expressed their own concerns as they are not involved in the recruitment process, which is managed by the Human Resource Team. They said they have raised this with the management team of Msaada Care Ltd. The staff training records and training matrix viewed, showed staff had received training ranging from completing an induction programme, health and safety, safeguarding adults, medicines, first aid, infection control, hoist and Abbotsford DS0000040840.V377528.R01.S.doc Version 5.3 Page 29 nutrition. Some staff had also receiving training in dementia awareness, mental capacity, taking temperature and blood pressure, supervision and appraisals. The Acting Manager confirmed over 50 of staff have attained National Vocational Qualification (NVQ) level 2 or above in care. Staff spoke positively about the support they have from their colleagues and the Acting Manager. Staff said the training provided was good and helped them support people safely and promoted people’s independence. Two staff spoken with said they were completing the 12 week dementia course and had demonstrated how they had put into practice the knowledge gained. The comments we received were: “You learn how dementia affects people and the need for consistency, patients and understanding” “I think people with dementia are probably more vulnerable as they appear ok and can be led easily” “It’s important to make sure they are cared for and do things for themselves as much as possible” We concluded that the staffing levels and the skills mix also benefits the people who use the service who promote their health, safety and well-being. Although staff recruitment is good, it could be improved with the input of the Acting Manager being involved in the recruitment process. Abbotsford DS0000040840.V377528.R01.S.doc Version 5.3 Page 30 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, 36, 37 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 benefit from a managed home, where they are consulted on the quality of service provided that promotes their health, safety and well-being. EVIDENCE: We wanted to find out whether the management of Abbotsford protects and promotes the well-being of the people who use the service. The information we gathered from the self-assessment completed by the Acting Manager stated they ‘employ a competent and experienced manager’ and is ‘training up to National Vocational Qualification (NVQ) level 4’. Abbotsford DS0000040840.V377528.R01.S.doc Version 5.3 Page 31 Since the last key inspection of the service, it was recommended that the Acting Manager submits an application to the Care Quality Commission to be assessed to become the ‘Registered Manager’. The Acting Manager said they still intend to submit an application and gave further assurance that this would be progressed quickly. The information in the ‘statement of purpose’ and the ‘service user guide’ should include the details and experience of the management team in the home. The Acting Manager told us staffing is stable and they are looking to recruit senior carers. The day staffing is covered by three staff, of which, one is designated as a ‘shift leader’ having specific responsibilities such as medication, whilst senior carers are recruited. We establish from speaking with the staff that deployment of staff has improved. Staff said they have clear roles and have key-worker responsibilities. The comments and responses received in the surveys from the people who use the service, their relatives and the support with regards to the management of the service were positive. The comments received included: “I think the home and the service has improved since …. (Acting Manager) has taken over. She always talks, sorts out any problems with me over mum when asked. I also think the standard of the home has improved” “The manager is very positive, she guides us (staff) properly” “The home is like a big family” “I love the manager and my colleagues” “….. (Acting Manager) is good too, you always see her around and comes and talks to us” We wanted to find out what quality assurance systems, checks and consultations take place with the people who use the service. The Acting Manager said that they had conducted a quality assurance survey recently and was collating the results. We read the draft report produced by the Acting Manager. The responses received were positive and also provided some statistical information. We discussed with the Acting Manager that some consideration should be made to making the report suitable for the people who use the service. We also suggested that consideration should be made to measuring the outcome of the quality assurance against the statement of purpose. This would show if people’s experiences and expectations of the service are consistent with what the service had stated as the aims and objectives. Abbotsford DS0000040840.V377528.R01.S.doc Version 5.3 Page 32 People who us the service said they have meetings at the home on a monthly basis with the Acting Manager. These are known as ‘residents meetings’. People said they felt involved and their opinions mattered. They said, “ …. always asks us if there are any issues, we always talk about the meals – it’s important to us” “We like to have a say” “Not everybody says how they feel about things but others do” We read the minutes of the ‘residents meeting’, which was displayed on the notice board and minutes of the previous meetings. There were set agenda items and these meetings were attended by most people who use the service. The topics discussed were the facilities and accommodation, activities, meals and any other business. We saw a number of cards and letters of thanks in the Acting Manager’s office. These were sent from the people who use the service and relatives. This showed people had good experiences of the service and the care they or their relatives received. We suggested to the Acting Manager that they should keep a record of the compliments the home receives, which like the complaints and the quality assurance surveys, can be used to measure the quality of the service people receive. The Acting Manager said they have had the monthly visits and reports from those visits, known as ‘Regulation 26 visits’. These are carried out by the representative of the ‘Responsible Individual’ who is the registered owner. We read the visit report of 29th June 2009. It demonstrated people who use the service were consulted; records were checked such as care files, menus, residents and staff meeting minutes and health and safety checks on the environment, safe storage of medicines and fire checks. The report was concluded with an action plan that was given to the Acting Manager to address. We concluded from the above evidence gathered that people who use the service are consulted about the quality of service they receive and there are internal monitoring systems in place. We wanted to find out how people are supported to manage their own money. One person said they ‘like to have some pocket change but preferred the home looking after the money’. The Acting Manager described and showed us the records to demonstrate the system in place to manage people’s money. We concluded that there is a good system in place whereby, people’s money held in safe-keeping is protected, managed safely and records are auditable. The staff surveys responses indicated staff have regular team meetings and receive regular supervisions and appraisals. This was consistent with what staff Abbotsford DS0000040840.V377528.R01.S.doc Version 5.3 Page 33 told us. The staff files had old supervision records; however, the supervisions conducted by the current Acting Manager are kept confidential. The staff meetings take place every two months. We read the minutes of the staff meetings held on 30th June 2009, which covered the topics of handover meetings, training, shift leader and key worker roles and water pressure. The minutes of the previous meeting held on 24th April 2009 covered the topics of communication, care plans, training, rota, menus and choices, sickness procedures, activities, cleaning, beds and the laundry. We concluded that staff are supervised and kept informed on issues, updates and changing practices. The information we gathered from the self-assessment completed by the Acting Manager detailed the programmed of routine maintenance, servicing and testing of equipment in the home. People who use the service told us they are told when staff are carrying out fire tests and checks on equipment. Evidence of the fire tests and routine safety checks carried out is recorded and shows these take place at regular intervals. The Acting Manager confirmed the Fire Service carried out an inspection on 11th August 2009 and the report has not yet been received. The care plans read for the people we case tracked also reflected the safety measured staff should follow to ensure people’s safety. There was evidence of care plans and risk assessments being reviewed on a monthly basis. This showed people’s care needs, their health and safety was monitored regularly. The staff training records viewed should staff had received training in moving and handling, infection control, health and safety, which includes using equipment such as a hoist. This showed staff skill-mix is maintained in line with current best practice. We concluded that the home environment is safe and well-maintained and trained staff ensure people who use the service are protected and their wellbeing is promoted. Abbotsford DS0000040840.V377528.R01.S.doc Version 5.3 Page 34 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 1 X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 3 X X 3 3 1 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 3 3 3 Abbotsford DS0000040840.V377528.R01.S.doc Version 5.3 Page 35 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 OP1 Regulation 4(1)(c) Requirement The registered person must ensure the statement of purpose and the service user guide is updated to reflect the changes in management: the registered provider and any registered manager. This includes relevant qualifications, skills and experience. To ensure people are informed correctly about the service and the management. The registered person must ensure care plans includes key information and is person centred. This includes any known allergies, dislikes and to develop the person centred care plans that are holistic and personalised. To ensure individual routines, preferences are known and level of independence is maintained that promotes their well-being. The registered person must ensure all areas of the home used by people free from offensive odours. DS0000040840.V377528.R01.S.doc Timescale for action 07/10/09 2. OP7 15 15/10/09 3. OP26 16(2)(k) 15/10/09 Abbotsford Version 5.3 Page 36 To ensure people’s health, wellbeing and dignity is promoted. 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. Refer to Standard OP1 OP1 Good Practice Recommendations The home’s ‘statement of purpose’ and ‘service user guide’ should be available within the home for all people that use the service and their representatives. The statement of purpose and service user guide should be made available in alternative formats to suit the needs of the people who use the service and prospective users of the service. The assessment of needs should be reviewed and updated to take into account the ability and capacity of people to make decisions in accordance with the ‘Deprivation of Liberty’ and the ‘Mental Capacity Act 2005’. To consider developing menus in alternative formats to enable people with dementia to make choices. To consider seeking advice from the Dietician to ensure people have a nutritional and balanced diet. To consider seeking advice from organisations that promotes and advocates the needs of people with dementia when considering the decoration of the home. This includes floor covering and décor that would promote people’s orientation and safety around the home. All staff files should contain evidence of relevant valid work permit where overseas staff are employed. The recruitment process should have the involvement of the manager of the service, who is able to assess the qualities of the applicant to compliment the staff team and benefit the people who use the service. The home should work towards having all the staff trained to NVQ level 2 and above in care. It is strongly recommended that the Acting Manager should consider submitting an application to CQC to becoming the registered manager. This recommendation was made at the last key DS0000040840.V377528.R01.S.doc Version 5.3 Page 37 3. OP3 4. 5. 6. OP15 OP15 OP19 7. 8. OP29 OP29 9. 10. OP30 OP31 Abbotsford 11. 12. OP33 OP33 13. OP33 inspection of the service: 14th October 2008. To consider developing a report on the finding from the quality assurance survey that is shared with the people who use the service. To consider measuring the findings from the quality assurance survey against the statement of purpose to ensure people’s expectations and experiences of the service is consistent with the aims and objectives of the service. This would also assist in the review and updating of the statement of purpose. To consider maintaining a record of the compliments and commendations received by the service from the people who use the service, relatives and other professionals. Abbotsford DS0000040840.V377528.R01.S.doc Version 5.3 Page 38 Care Quality Commission East Midlands 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). 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. 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