CARE HOMES FOR OLDER PEOPLE
Abacus Care Home 42/44 Rolleston Road Burton On Trent Staffordshire DE13 0JZ Lead Inspector
Rachel Davis Key Unannounced Inspection 3rd July 2007 09:50 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 Abacus Care Home DS0000066436.V338590.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. Abacus Care Home DS0000066436.V338590.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Abacus Care Home Address 42/44 Rolleston Road Burton On Trent Staffordshire DE13 0JZ 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) 01283 533166 01283 533310 steven.sadhra@btconnect.com Dr Steven Sadhra Mrs Dilvinder Kaur Sadhra Vacant post Care Home 24 Category(ies) of Dementia - over 65 years of age (24), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (1), Old age, not falling within any other category (24), Physical disability over 65 years of age (5) Abacus Care Home DS0000066436.V338590.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 28th September 2006 Brief Description of the Service: Abacus House is a residential care home offering 24 places; the home is registered to take older people with dementia, it has 5 places for those with a physical disability and one placement for an older person with mental frailty. Abacus House is a two-storey extended house; it is situated in a residential area of Burton upon Trent, affording people who use the service the opportunity of maintaining links with the neighbouring community. It is well placed for the local amenities and the home has the facility of a main bus route. Both the exterior and interior of the property are very well maintained, it is exceptionally clean and the décor is set to a good standard. The people who use the service are offered easy access to all areas of the home by the use of grab rails and a lift. All bedrooms are of single occupancy and meet the required sizes set out by the national minimum standards; they are equipped with suitable fixtures and fittings. The bathrooms and toilets are well located and offer appropriate equipment and facilities. Communal areas are spacious and comfortable; the downstairs dining area opens into a large conservatory overlooking a mature and well-kept garden. Patio areas with seating are available and easily accessed. Satisfactory car parking is available. Abacus Care Home DS0000066436.V338590.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The unannounced inspection took place over seven and a half hours, this was a ‘key inspection’ and therefore all the core standards were assessed The methodologies used were: A day of preparation before the inspection, including scrutiny of the questionnaires completed by people who use the service, their relatives and health care professionals. During the visit the inspector met and spoke to the people living in the home, visitors and the majority of staff on duty. The manager and owner of Abacus House were not on site but both attended for part of the inspection. Observations were made of staff and resident interaction around non-personal care tasks, lunchtime and the medication administration and systems were also seen. A tour of the home was taken and some of the people living in the home showed the inspector their bedrooms. Care plans were checked and the records of two staff (both employed since the last inspection) including recruitment and training documents were seen. There have not been any complaints made to the Commission for Social Care Inspection about the service delivered at Abacus House since the last inspection held in September 2006. The manager Kim Johnston has been in post for 6 months and is presently undergoing the necessary registration process with the Commission for Social Care Inspections registration team. The fees charged are £390:00 per week. What the service does well:
The home prioritises the needs of the people who use the service ensuring that their wishes and feelings are continually assessed and met. The home has begun to operate a person centred approach and demonstrates a good understanding of the individuals care needs. The home provides an excellent range of care planning documents and risk assessments for each person who uses the service, demonstrating a commitment to enabling people to have some control over their lives. Residents’ descriptions of the home were as follows:
Abacus Care Home DS0000066436.V338590.R01.S.doc Version 5.2 Page 6 “ They look after me well.” “ I like living at Abacus House.” “ We have two very good cooks.” Relatives’ comments included: “ Excellent all round, especially the care given to my dear relative” “On entering Abacus House the hall and stairways always look as though they have just been hoovered. I have never experienced any unpleasant smells so feel reassured that the necessary care and work is going on behind the scenes.” “ I have seen meals at the home that are very good.” Health needs are closely monitored and access to other health professionals is arranged as required, emotional needs appear to be addressed with care and sensitivity. The home ensures staff are not employed without full employment checks therefore confirming they are suitable people to work with vulnerable adults. All newly appointed staff undergo an appropriate induction programme to promote good practice, confidence and understanding in the service delivery, there is a commitment to National Vocational Qualification training for all staff. The management of residents’ monies is robust and safe. Activities are available for those people using the service who are able to participate and trips have been organised. What has improved since the last inspection?
Since the last inspection a permanent manager has been appointed, Kim Johnston, Kim is presently being registered with the Commission for Social Care Inspection. This affords the home leadership, stability and continuity. Abacus House has a committed responsible individual, Mrs Sadhra, who visits the home on a regular basis. With a new owner and a new manager over the last twelve months a period of great change has occurred and this in itself has raised a number of issues. Following discussions it was evident that there is a clear vision, and the aims, objectives, culture and ethos of the management team will have a positive impact on the people who use the service. Abacus Care Home DS0000066436.V338590.R01.S.doc Version 5.2 Page 7 Individual risk assessments are now in place for identified areas of risk, mental, physical and emotion assessments were seen on care plans and offered meaningful and informative advise. The home has consulted the people who use the service on the variety, choice and information provided around mealtimes. When people were asked do you like the meals? , 11 people who use the service said always, 4 said usually and no-one said sometimes or never. “ Food very good. “Choice seems good.” Were comments made. The manager has ensured the staff are provided with training appropriate to the work they are to perform, staff confirmed training had been “thought provoking” and “ much improved.” Abacus House have enrolled all their care staff on a 13-week dementia course and following this will offer some staff training in mental health as required. Other courses recently undertaken include: fire evacuation, foot care, diabetic awareness, hoist training, continence care, health and safety including infection control. The manager has commenced thorough and meaningful supervision sessions with all staff. Appraisals will commence in the near future. The owner has carried out the unannounced monthly visits and completed an appropriate record of such visits to comply with regulation. This enables them to form an opinion of, and to monitor the standard of care provided at Abacus House. The home has robust fire risk assessments, records, floors plans and information in the event of a fire. It also has a safe placement procedure for the people who use the service. The manager has encouraged people to use the comments, concerns and compliments book. What they could do better:
Following this inspection it was apparent that there are two areas of concern, one is the medication administration, recording and disposal procedure. The other is information received by people who use the service and/or their visitors on some staff practices. The medication procedures observed were unsafe and potentially put vulnerable people at risk. See Health and Personal Care section of this report. Comments received by the Commission for Social Care Inspection included: “ Sometimes there are no staff available in the communal area where the residents are sitting.”
Abacus Care Home DS0000066436.V338590.R01.S.doc Version 5.2 Page 8 “Staff take breaks together leaving the residents unsupervised.” When discussed with the owner and the manager during this inspection it was clear they were aware of this issue and have put measures in place to address this. Examples include, only one member of staff is allowed to go on their break at any one time, charts have been implemented to record 15 minute checks on all communal areas. Minutes of meetings are made available for all the staff to read, follow up meetings are going to be arranged. 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. Abacus Care Home DS0000066436.V338590.R01.S.doc Version 5.2 Page 9 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 Abacus Care Home DS0000066436.V338590.R01.S.doc Version 5.2 Page 10 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): 2 and 3. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Information offered ensures that people who use the service and prospective residents can make an informed choice about the home. EVIDENCE: The care records of two recent admissions were checked and contained the needs assessment as required. The manager had assessed the needs of the residents prior to admission and a 72-hour plan and then a subsequent care plan had been developed, this affords staff all the information necessary to provide individualistic care. Those spoken to, or information received demonstrated very positive comments about the home and their admissions policy: Questionnaires sent by the Commission for Social Care Inspection ask- Abacus Care Home DS0000066436.V338590.R01.S.doc Version 5.2 Page 11 Q1. Have you received a contract? Q2. Did you get enough information regarding the home before moving in? On both counts 100 of returned questionnaires said yes. The home also provides the people who may use the service or their families with a “ Getting to know you” booklet, this covers areas such as family and friends, before you came to Abacus House, hobbies and past employment to give a picture of the person prior to them requiring 24 hour care. Other comments: “I was shown around the home and I’m impressed with what I have seen.” “ I visited the home before I moved in.” The owner of Abacus House recorded on the Annual Quality Assurance Assessment (this is a legal document that must be completed by the home for the Commission for Social Care Inspection) that, “We encourage visits from prospective residents and families to be unannounced.” The home operates a key worker and a named worker system to help individuals feel comfortable in their new surroundings, and enable then to ask any questions about life in the home. Standard 6 is not relevant to this home and therefore not assessed. Abacus Care Home DS0000066436.V338590.R01.S.doc Version 5.2 Page 12 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The health and personal care needs that the people who use the service receive are individualised. Medication administration and recording was observed, it was seen to be unsafe, this potentially put people who use the service at risk. EVIDENCE: Since the last inspection a new care planning system has been introduced which is being completed for everyone living in the home. There was excellent information within these plans of care that gave a real insight into the person receiving support from Abacus House. New care plans were person centred and all people who use the service have a key worker and a named worker, evidence was available to confirm the care plans were regularly reviewed and the manager is ensuring that this will be with input from the person who uses the service. Daily records and daily statements were also evident with management plans and risk assessments in place where needed. It was recommended that daily
Abacus Care Home DS0000066436.V338590.R01.S.doc Version 5.2 Page 13 records should not have gaps, this ensures records are not written retrospectively. Two general practitioners comment cards confirmed that Abacus House has a clear understanding of the needs of the people who use the service, take appropriate decisions and work in partnership. Medication procedures were observed, were unsafe, and do not meet with the regulations. Observations were as follows: Medication was signed off as administered on the Medication Administration Sheets before it was offered. Medication was “shared” i.e. One resident’s medication was given to another resident also. Senior staff informed the Commission for Social Care Inspection that medication was disposed of down the sluice. Medication was signed off as being given to a resident the day before but it was found in the residents’ bedroom the following day. Some medication information was ambiguous and staff were deciding whether or not to administer and/ or how much. Of the 5 items stored in the medical fridge only 1 was dated on opening as required. Fridge temperatures were not recorded as necessary. Information on comment cards read as follows: “One evening my relative visited and found a medicine measure containing a tablet on the top of the TV in my room.” “Medicines not always given on time and regular tablets sometimes given at different times.” People who use the service are encouraged to self medicate following an assessment, one person is self medicating but an assessment was not in place. The Commission for Social Care Inspection spoke at length with the owner who is taking immediate steps to rectify this situation. There was evidence to verify the management team had provided senior staff with the homes’ medication policies and procedures, staff had signed on receipt in January 2007. There was also evidence to confirm the staff had received appropriate training in the management of medication. Abacus Care Home DS0000066436.V338590.R01.S.doc Version 5.2 Page 14 Abacus Care Home DS0000066436.V338590.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Activities and stimulation for people who use the service are in place, this provides daily variation and interest for people living at Abacus House. The home encourages and welcomes visitors. EVIDENCE: Sufficient staff resources are provided to allow time for activities and stimulation. The home operates a key worker system, which enables closer resident staff relationships where likes, dislikes and needs are shared and also recorded. When asked about activities the following responses were offered. Q. Are there activities arranged by the home that you can take part in? Always X 7 people who use the service said so Usually X 4 people who use the service said so Sometimes X 4 people who use the service said so Never X 0 person who uses the service said so
Abacus Care Home DS0000066436.V338590.R01.S.doc Version 5.2 Page 16 Activities are also recorded giving information on who undertook the activity, what it was and which residents participated. When outside entertainers are provided there is room in the conservatory for everyone to attend. On the afternoon of the inspection the people who use the service enjoyed a sing-along. It was mentioned that“ Visiting singers and musicians are particularly good.” Staff and the people who use the service were preparing for their Summer Fete and the residents were designing a banner, those residents who wished to do so were managing stalls. From the records available it was clear there were regular visitors to the home. During this inspection visitors confirmed they were made welcome at any time. A number of people who use the service said that they often went out of the home with relatives and friends. A recommendation was made to look at further ways of ensuring people without family support, or people who use the service with dementia are encouraged and supported to maintain links with the community. People who use the service were able to receive visitors whenever they chose, as the home has an open visiting policy, this was verified by a visitor on the day of the inspection. People who use the service could choose to see their visitors within their own private accommodation if they preferred to do so and this was also evidenced during the inspection process. Food was considered by the residents to be ‘very good’, the cook has also introduced a new 4-week menu which has been well received. People who use the service and require support with their meal are given assistance on a one to one basis. It was disappointing to see one member of staff standing up to help to support a resident to eat their meal, this disempowers the individual, a more sensitive approach is required. An environmental health officer had recently undertaken an inspection and no requirements were made. Abacus Care Home DS0000066436.V338590.R01.S.doc Version 5.2 Page 17 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home has a suitable complaints procedure and people who use the service are encouraged to express their concerns, training in the protection of vulnerable adults has been provided to all staff. EVIDENCE: There is a copy of the complaints procedure displayed in the entrance hall and leaflets are available to take away if required. The home also has a box where people can deposit their questionnaires or a comment/concern. A comment, compliments book has also been introduced which is being actively used. Information about how to make a complaint is also contained in the Service User Guide. Abacus House has an open culture that allows people who use the service and their relatives to feel comfortable about expressing their views. Resident relative meetings are also held monthly, these are minuted and copies are provided to all. Unfortunately the homes computer system had recently crashed and information to verify that all complaints had been recorded and dealt with in a satisfactory manner was not available. The information that was available confirmed that this was highly likely. One questionnaire returned also verified that a system had been put in place to help with resolution.
Abacus Care Home DS0000066436.V338590.R01.S.doc Version 5.2 Page 18 It must be noted that when asked Do you know how to complain? 8 people who use the service said yes and 4 said no, one person said “If something is wrong I would tell the girls on duty but I do not know if this is what I should do.” Another recorded “ Since change in ownership it is more difficult to know who to approach. Some of the carers are good at dealing with issues others less so.” The home should take steps to ensure everyone is clear of what to expect and who to talk to. Abacus House has adult protection procedures in place and the owner, manager and staff had received training in this area. It is recommended that the Protection of Vulnerable Adults is revisited due to observations around the mismanagement of medication. Abacus Care Home DS0000066436.V338590.R01.S.doc Version 5.2 Page 19 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, 20, 21 and 26. Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. People who use the service live in a safe and well-maintained environment. EVIDENCE: The management and staff encourage people who use the service to see the home as their own home. Abacus House is a very well maintained, safe, comfortable and attractive home Robust infection control measures are in place, examples of this include: paper towels, liquid soap, laundry management and personal protective clothing. The home employs a maintenance person who carries out any required maintenance on an ongoing basis.
Abacus Care Home DS0000066436.V338590.R01.S.doc Version 5.2 Page 20 On talking with staff it was evident that they were aware of issues about cross infection and a recent “outbreak” was handled well. It was observed that staff were sensitive towards the privacy and dignity of people who use the service. Achieving this standard of domestic housekeeping must be complimented as being commendable. Comments received were “ Its my home.” “ I’ve been shown round and was impressed with what I saw” “ Abacus is always clean and fresh.” “Seeming as they have to do cleaning and laundry they do a good job.” It must be noted that more domestic hours have recently been provided.” Laundry management could require revisiting, 3 people confirmed that their clothes had gone missing. Abacus Care Home DS0000066436.V338590.R01.S.doc Version 5.2 Page 21 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): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Staff recruitment procedures are sound and there was evidence to show staff training has improved. Concern around some staff practice was apparent during the inspection process EVIDENCE: Two staff files were examined and both demonstrated that the manager had conducted a thorough recruitment practice. This included 2 written references, application forms that offered a full employment history, the required identification certificates, health declaration, photograph and Protection of Vulnerable Adults First and enhanced Criminal Record Bureau disclosure. No male staff are presently employed within the home, if this were possible it would help to promote equality and choice. All staff within the home have received positive and meaningful training, the manager has prioritised training and enabled staff members to undertake specialist training beyond the basic requirements. This ensures a consistent and needs led service is offered to the people who use the service. The service clearly defines the roles and responsibilities of staff through accurate job descriptions and specifications.
Abacus Care Home DS0000066436.V338590.R01.S.doc Version 5.2 Page 22 The Commission received a number of comments for Social Care Inspection from people who use the service and their families, some are as follows: “Staff will only help me clean my own teeth if I ask them to.” “Sometimes the call button is not in easy reach, this happened on 2 occasions last week.” “Not always a member of staff present in the conservatory, people have fallen over and another resident has to press the call button.” Other people who use the service commented that when they are in their bedrooms some staff do not “ pop their head round” one resident said if they did it would “show they care.” When discussed with the owner and the manager during this inspection it was clear they were aware of these issues and have put measures in place to address this. Examples include, only one member of staff is allowed to go on their break at any one time, charts have been implemented to record 15 minute checks on all communal areas. Minutes of meetings are made available for all the staff to read, follow up meetings are going to be arranged. On balance a number of people who use the service and visitors were very happy with the care they receive: “Excellent all round” “They are polite and kind.” “They always knock before entering my room.” “Coming to Abacus House was the best thing my family could have done for me.” Out of 22 care staff 11 have a National Vocational Qualification in Care level 2 and 6 are currently undertaking the qualification. Three staff have left over the last 12 months. Abacus Care Home DS0000066436.V338590.R01.S.doc Version 5.2 Page 23 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The management team are closely monitoring the quality of the service and making changes and improvements where identified and required. EVIDENCE: Kim Johnston is the manager of Abacus House and has been in post for approximately 6 months she is presently being registered with the Commission for Social Care Inspection. Mrs Sadhra has owned Abacus House for a year and visits the home on a regular basis. People who were spoken to were happy with the management team and felt they were approachable, some people who use the service, visitors and staff
Abacus Care Home DS0000066436.V338590.R01.S.doc Version 5.2 Page 24 said that Kim spends the majority of her time in the office , it was recommended that more time on the floor may prove advantageous to ensure people who use the service feel involved with the running of their home. The management team closely monitors the practices in the home and there is a robust quality assurance system, action plans are developed and reviewed as required. A business plan for 2007/2008 was evident. Suitable insurance was in date until February 2008 and all information that must be offered to people who use the service or prospective residents is in place. The home maintains robust systems and records of all residents’ finances and property. These were seen by the Commission for Social Care Inspection and are regularly audited by the home. Staff are now regularly supervised and records made, the manager will shortly commence the appraisals as required under regulation. The home is well maintained and records kept including comprehensive fire risk assessments. Abacus Care Home DS0000066436.V338590.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 4 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 4 4 X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Abacus Care Home DS0000066436.V338590.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes 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 OP9 Regulation 13(2) Requirement When medication is administered to people who use the service it must be accurately recorded, to ensure people receive the correct levels of medication, therefore maintaining their wellbeing and safety. Medication must be disposed of according to the homes policy. People who use the service and wish to self medicate must be assessed accordingly, this is to ensure they are safe to do so. People who use the service must be confident that their health and welfare needs are met and promoted by all staff at all times. A proportion of staff need to be provided with mental health training, this ensures the home can demonstrate that the have the skills necessary to meet the needs of the people who use the service. Previous requirement not met from last inspection held in September 2006. The home must produce an improvement plan setting out
DS0000066436.V338590.R01.S.doc Timescale for action 07/07/07 2 3 OP9 OP9 13(2) 13(4)(b) 07/07/07 07/07/07 4 OP27 12(1)(a) 07/07/07 5 OP30 18(1)(c) 03/10/07 6 OP31 21A 02/09/07 Abacus Care Home Version 5.2 Page 27 the methods by which, and the timetable to which, the registered person intends to improve the medication practices. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP7 OP9 OP13 Good Practice Recommendations It is recommended that the daily records for people who use the service are completed without gaps. It is recommended that the continuing competency of staff administering medication is assessed on a regular basis. It is recommended that the home look at further ways to ensure people with dementia, or without family, are encouraged and supported to maintain links with the local community. The home are advised to revisit the vulnerable adults policy with staff to ensure all staff are aware of its content. The home may wish to revisit their laundry management systems as questionnaires, the comments book and discussion confirmed clothes do go missing. Although the home is proactive in promoting equality and diversity it should continue to consider ways in evidencing this within their service. Due to the difficulties that managing change can bring the manager may wish to consider spending some more time with the people who use the service to support her in decision making. 4 5 6 7 OP18 OP26 OP30 OP32 Abacus Care Home DS0000066436.V338590.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Stafford Local Office Dyson Court Staffordshire Technology Park Beaconside STAFFORD ST18 0ES 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
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