Inspection on 01/06/05 for Abbendon Nursing Home

This inspection was carried out on 1st June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Abbendon Nursing Home 28/06/07

Abbendon Nursing Home 04/10/06

Abbendon Nursing Home 02/11/05

Abbendon Nursing Home 20/10/04

Abbendon Nursing Home 18/05/04

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Abbendon Nursing Home 45 Scarisbrick New Road Southport Merseyside PR8 6PE Lead Inspector Claire Lee Unannounced 01 June 2005 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 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. Abbendon Nursing Home F53 F03 S17215 Abbendon V226415 160505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Abbendon Nursing Home Address 45 Scarisbrick New Road Southport Merseyside PR8 6PE 01704 538663 01704 884110 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Mark Gilbert Miss Valerie Atherton Care Home 24 Category(ies) of DE Dementia 24 registration, with number of places Abbendon Nursing Home F53 F03 S17215 Abbendon V226415 160505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users to include up to 24 DE Dementia. Date of last inspection 20th October 2004 Brief Description of the Service: Abbendon is a large detached property that has been converted in to a care home. It provides care for 24 older persons who have enduring mental health needs. The home is privately owned by Mr and Mrs Mark Gilbert. Mr Gilbert also owns other homes in the area as part of the Dovehaven group. Abbendon was previously registered as general nursing and the philosophy and skill mix is now particularly focused on caring for physically frail residents who have care needs associated with dementia and confusion. Abbendon is situated in a residential area of Southport close to the town centre, local amenities and public transport. The home is situated over 4 floors and provides 14 single rooms and 5 double rooms. Abbendon has an attractively decorated lounge on the ground floor and a conservatory has recently been added to the first floor at the rear of the building. The home has a lift to all floors and ramps are provided for wheelchair access to the main front door. There is ample car parking space and a large enclosed garden at the rear. Abbendon has bathrooms with adapted equipment to assist less able able residents and a call system with an alarm facility is functional through the home. Abbendon Nursing Home F53 F03 S17215 Abbendon V226415 160505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 7 hours. It was an unannounced visit and was carried out as part of the regulatory requirement for care homes to be inspected at least twice a year. There has been no cause for any visits to the home since the last routine inspection in October 2004. The manager, 5 staff members, 4 of the 24 residents and 2 relatives were spoken with and their views obtained of the home. Satisfaction comment cards were also given to residents and relatives to complete at their leisure. Comments have been favourable regarding the home and the very professional and caring attitude of the staff. What the service does well: The health and personal care needs of residents are well met. An assessment for a resident who was recently admitted was viewed and this was completed in good detail. Assessments from social services and other community based teams assist the manager with the initial assessment process. This ensures the staff are able to meet residents’ health needs in full. A relative commented on the good care given by the staff and their understanding of the problems that a resident may feel when entering a care home. Care files of residents included detailed records of physical, psychological and social needs. Activities of daily living were completed, for example, eating, breathing, elimination, sleeping, mobility and dressing. The care plans also place emphasis on understanding the behavioural needs of the residents and a psychological ‘snapshot’ records these relevant details. The care plans are easy to follow and provide a sound basis to organise the care. Care staff are prompt to report any problems as they arise and the registered nurses are competent when assessing and planning care. Care files viewed also evidenced referrals to external health professionals at the appropriate time. Abbendon Nursing Home F53 F03 S17215 Abbendon V226415 160505 Stage 4.doc Version 1.30 Page 6 The home has a stable team of staff and they were observed assisting residents in a professional, calm and gentle manner. The home had a pleasant relaxed atmosphere and at the time of the inspection all areas were very clean and hygienic. The home has a minibus and staff accompany residents on outings each week. Some residents prefer to stay at the home and this wish is respected. An occupational therapist arranges hobbies and musical entertainment on a Friday and a resident said, “it is nice to have this entertainment.” Residents enjoy meal times and staff were observed providing the right level of support for residents who need some degree of help. A resident said, “the food is good and tasty.” The home is maintained to a very good standard and all areas are attractively decorated with pleasing colour schemes. Resident bedrooms are individual and have personal items such as photographs, pictures and ornaments. A resident who has recently been admitted said, “I am very pleased with my room, it is warm and cosy and it has everything I need.” There are security systems in place to ensure the safety of the residents. What has improved since the last inspection? What they could do better: Medicine sheets must record the date and quantity of medicines received in to the building to ensure an audit trail can be conducted of each medicine prescribed. Staff must sign resident medicine charts following administration of a prescribed medicine including wound dressings, external creams and prescribed meal supplement drinks. All staff must receive mandatory training, including manual handling, first aid, food hygiene and health and safety. This ensures competency in their role and Abbendon Nursing Home F53 F03 S17215 Abbendon V226415 160505 Stage 4.doc Version 1.30 Page 7 records must be kept of training undertaken. Staff must receive induction on commencement of their employment to ensure they fulfil the aims of the home and meet the needs of the residents in their care. In order to meet health and safety fire alarms are be checked weekly and the result of the tests recorded in the home’s fire logbook. Fire records evidenced a fire drill in 2003 and therefore it is recommended the home refer to the guidelines given by the fire service department regarding the frequency of fire drills for care homes. Advice should also be sought regarding the closure of fire doors as some were found to be wedged open. Fire awareness training is required for staff and it was agreed this would be arranged this month. The hot water supply to the baths is regulated to deliver water at a safe temperature however records must be maintained of these temperatures. 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. Abbendon Nursing Home F53 F03 S17215 Abbendon V226415 160505 Stage 4.doc Version 1.30 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Abbendon Nursing Home F53 F03 S17215 Abbendon V226415 160505 Stage 4.doc Version 1.30 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 The manager assesses the residents psychological and physical care needs prior to and during the early stages of admission to the home. This ensures that the home is capable of caring for and meeting the needs of residents. EVIDENCE: Individual records are kept for each resident and the manager completes the assessment documentation prior to admission. An assessment of a resident who had recently been admitted to the home was viewed. The notes taken included nursing needs, for example, skin care, mobility, nutrition and help with washing and dressing. Psychological needs and family involvement were also recorded in detail. If a resident is unable to provide this detail then as much information as possible is obtained from other sources including relatives, social services, hospital and community psychiatric staff. The information is then collated to form the basis for the resident’s plan of care. Staff interviewed were able to describe the care needs for the residents discussed. Abbendon Nursing Home F53 F03 S17215 Abbendon V226415 160505 Stage 4.doc Version 1.30 Page 10 Abbendon Nursing Home F53 F03 S17215 Abbendon V226415 160505 Stage 4.doc Version 1.30 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9 and 10 It was clear that that the health, personal and social care needs of residents were understood and set out in an individual plan of care. This ensures a good overall standard of care in the home. EVIDENCE: Each resident had an individual plan of care that identified relevant aspects of health, social, psychological and personal care. The care plans were detailed, clearly set out and easy to read. Regular reviews had been conducted and changes made to the plan of care where needed. This was seen in relation to a resident who had recently been admitted to hospital following fall and the changes made to her care plan on her return. Relatives are approached regarding the agreement and consent to the plan of care and are involved in the 6 monthly formal reviews. This was recorded in the files viewed. Abbendon Nursing Home F53 F03 S17215 Abbendon V226415 160505 Stage 4.doc Version 1.30 Page 12 Residents who had medical conditions, for example, diabetes, were being monitored by staff. Their care files also included details of annual reviews carried out by the community diabetic team. One resident was receiving specific orthopaedic care and the requirements for this were recorded in detail in the plan of care. Discussion with staff confirmed their understanding of the care provision. A specialist mattress was in place for this particular resident and their manual-handling chart reflected the instructions for transfer from bed to chair. Optical and dental appointments are arranged regularly on behalf of the residents and a chiropodist visits the home. With regards to the psychological needs of the residents, a plan of care is gradually built up over a period of time. Staff interviewed were knowledgeable regarding the different ways in which the residents like to communicate. Details of their personal likes and dislikes regarding food, colour, noise, family, hobbies, sleep pattern and general behaviour were also recorded. If a resident is very agitated then these bouts of agitation are monitored carefully by staff and are detailed in their plan of care with reference to the cause and treatment. Residents can see their own GP unless moving away from his/her area and these visits along with hospital, optical and chiropody appointments were recorded in the care files. During the inspection a member of staff accompanied a resident for a hospital appointment and sufficient time was allocated for the resident to enjoy the time away from the home. Medicine sheets were signed and dated by staff however the quantity and date of medicines received in the building was not always recorded. External creams, wound dressings and meal supplement drinks must also be signed for by staff following their administration. This is required to ensure an audit trail of each medicine can be undertaken. The home’s medicine trolley is kept locked in a clinical room when not in use. Staff receive medicine awareness training and literature is available for the home on medicines administered. The manager is knowledgeable regarding the medicines prescribed for dementia and liaises regularly with residents’ GPs regarding the most effective dosage and time of their administration. The return of controlled medicines to the home’s pharmacy was discussed as a problem was identified during the inspection. This was however rectified by the manager immediately. Staff interviewed discussed how the privacy and dignity of the residents is respected. During the inspection staff were observed knocking on doors before entering and using first name or calling the resident by their preferred name. A resident said, “the staff are always so polite and so kind.” Abbendon Nursing Home F53 F03 S17215 Abbendon V226415 160505 Stage 4.doc Version 1.30 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 and 15 There was a pleasant, relaxed and friendly atmosphere in the home. The daily life and routine is based around the residents’ individual needs and expectations. Meal times and social activities are both well managed and enjoyed by residents. EVIDENCE: The home has programme of events and hobbies that are arranged by staff and an occupational therapist. Events and activities for the residents were displayed on a notice board in the main hall. A trip out is arranged every Wednesday and staff accompany residents for these excursions. Relatives are also welcome to join in. The occupational therapist arranges weekly music sessions, reminiscence therapy, manicures, aromatherapy, card games dancing and games. The residents’ preferred interests are recorded in their plan of care and given according to their wishes. During the inspection staff were seen spending time chatting with the residents about every day occurrences. The home has a new cook and she had made some changes to the menu. Staff stated that this was providing a greater choice of hot meals at lunchtime. Residents were pleased with the changes that have been made so far and were happy with the quality of the meals. The menu was on display in the main hall Abbendon Nursing Home F53 F03 S17215 Abbendon V226415 160505 Stage 4.doc Version 1.30 Page 14 and staff ask residents what they would like for each meal. Meal preferences were noted in the care plans. The kitchen was well stocked with fresh and frozen procedure and dry goods. The menu offered a good choice of hot and cold meals 3 times a day with light refreshments at other times. Hot breakfasts are cooked on request. Meals are served at set times however arrangements are flexible to suit individual needs. Some residents prefer to receive their meals in their rooms and this wish is respected. The conservatory on the first floor is used for dining space for those residents on the first and second floor. Abbendon Nursing Home F53 F03 S17215 Abbendon V226415 160505 Stage 4.doc Version 1.30 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 No complaints have been received however the home’s policy and the good level of communication between residents and staff would ensure any complaint received would be handled fairly and promptly. Residents and relatives were confident that if they needed to make a complaint this would be listened to and acted upon. EVIDENCE: In the instance of a complaint being received the details of the complaint would be logged and investigated by the manager. No complaints had been received at this time. As many of the residents are frail and not always able to communicate their wishes, staff meet regularly with relatives or an advocate to ensure there are no areas of concern. A resident said, “I have no worries at all, everything is taken care for me.” Interviews with staff confirmed their understanding of the complaint policy and what to do should a complaint arise. Discussion with a relative confirmed that the manager is available to talk with at any time. Abbendon Nursing Home F53 F03 S17215 Abbendon V226415 160505 Stage 4.doc Version 1.30 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,22,23,24,25 and 26 The layout and location of the home is suitable for older people and is homely and comfortable. The home is subject to an ongoing programme of general maintenance and redecoration to ensure residents benefit from a clean and safe environment. EVIDENCE: Since the last inspection a conservatory has been added to the first floor and this is used as an extra lounge and also dining space. It is not big enough for dining tables however residents have armchairs with coffee tables. Residents from the first and second floor were sitting in the conservatory and a resident said, “I like the sunshine here and the view.” All areas of the home were pleasantly decorated and the colour schemes chosen are restful to the eye. Drapes and bed linen are colour co-ordinated and residents’ bedrooms are individually decorated. The bedrooms had plenty Abbendon Nursing Home F53 F03 S17215 Abbendon V226415 160505 Stage 4.doc Version 1.30 Page 17 of personal belongings such as photographs, pictures and ornaments. A resident had some favourite items with her and these were arranged ‘exactly how she liked them’. Paintwork to skirting boards and door frames will need attention due to general wear and tear however this is included in the home’s annual maintenance plan. The main lounge is on the ground floor overlooking the front of the building. The room is spacious and has comfortable armchairs. Residents were enjoying music in this room and talking with staff. There are armchairs and coffee tables on the first floor landing and in the main hall. A keypad operates the doors on the first and second floor and also the main front door to ensure the residents are kept safe at all times. Each floor has a bathroom with a bath hoist to assist residents who are less able. The bathroom on the ground floor has a jacuzzi bath. The hot water supply to the baths is regulated to deliver water at a safe temperature however records must be maintained of these temperatures. It is also recommended that staff test the hot water prior to bathing service users and the home places hot water signs above the sinks. This will minimise any risk of injury to the resident. The home employs sufficient housekeeping staff to keep up a good standard of cleanliness in the home. All areas were very clean, tidy and hygienic. A relative said, “the cleanliness of the home is consistent.” The exterior of the home is well maintained and residents have the use of a rear enclosed garden. The main office for the Dovehaven group of homes is situated in a separate building. The home has ample car parking space to the front. Abbendon Nursing Home F53 F03 S17215 Abbendon V226415 160505 Stage 4.doc Version 1.30 Page 18 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29 and 30 Sufficient numbers of staff were deployed to meet the needs of the residents however some staff had not received the necessary training, to ensure competency in this role. Recruitment procedures were robust to safeguard and protect the people living in the home. EVIDENCE: A registered nurse is on duty 24 hours a day and inspection of the staffing rota and direct observation confirmed that sufficient staff were on duty at the time of the inspection. A member of staff assists in the cook in the mornings with general kitchen duties however there is no appointed kitchen assistant. Duties are currently split between laundry, kitchen and general maintenance and this can result in staff feeling pressured, it also compromises the time allocated to each area of work. Discussion with the cook confirmed that the home would benefit from employing a kitchen assistant and consideration should be given to this appointment. A vacancy exists for a full time carer and a registered nurse for Saturday nights. Permanent and bank staff currently fill any outstanding shifts. Discussion with a number of residents and two relatives confirmed that the home was ‘well staffed’ and that “staff work very hard to provide an excellent Abbendon Nursing Home F53 F03 S17215 Abbendon V226415 160505 Stage 4.doc Version 1.30 Page 19 home”. Comments included, “staff are kind, always cheerful and never rush me.” The manager has a training matrix on display in the office with the names of staff and names of courses available. A number of staff still require mandatory training including, manual handling, first aid, food hygiene and infection control. Health and safety training issues are discussed during induction however but no formal courses have been accessed. Manual handling instruction is arranged annually however four members of staff have not received this and it was agreed that this would be provided by the end of July 2005. The majority of staff have not received first aid training and this along with food hygiene is also required. A number of staff files viewed evidenced that training records for safe working practices were not up to date. The manager has arranged study sessions with regard to the care of the dying later this month. All staff receive training regarding the care of residents with challenging behaviour, dementia and Alzheimer’s. The home has plenty of research based documents and leaflets for staff, residents and relatives to access. The manger and registered nurses have also attended diabetes and leg ulcer management courses. The cook will be undertaking Intermediate Food Hygiene in July 2005. Induction is arranged for new staff however there was no evidence of a written formal induction given to a newly appointed registered nurse and cook. 95 of the care staff have attended a one-day accredited training day on induction standards. Again this information is to be evidenced. Staff meetings are held and minutes recorded. The manager also attends the local matrons’ meetings. The personnel files of 3 staff employed indicated that the home had undertaken all the necessary recruitment checks to ensure protection of residents. Protection of Vulnerable Adults [POVA] checks and Criminal Records Bureau checks at enhanced level were available. Two written references had been sought and this included information from the most recent employer. Abbendon Nursing Home F53 F03 S17215 Abbendon V226415 160505 Stage 4.doc Version 1.30 Page 20 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32 and 38 The manager provides leadership and direction to staff to ensure the residents receive a good standard of care. Some important records were not up to date to promote and protect the health and safety and welfare of the residents. EVIDENCE: The manager, Ms Atherton is a registered nurse and has managed the home for approximately 4 years. Ms Atherton has undertaken management courses and mandatory training for safe working practices. Ms Atherton has yet to complete an accredited course for dementia care however she keeps herself updated of changes in this field and implements best practice. Ms Atherton has some supernumerary time for general administration work however consideration should be given to an increase in these hours. This would assist with organising the staff training. The manager does not have a deputy however staff work closely as an effective team. This was observed during the inspection. Abbendon Nursing Home F53 F03 S17215 Abbendon V226415 160505 Stage 4.doc Version 1.30 Page 21 Comments received from residents and relatives were favourable regarding the overall management of the home and the professional attitude of the manager. A relative was full of praise for Val (manager) and said, “ she has been so kind and helpful, nothing is too much trouble and she is always at hand to talk to. We are very pleased with all the arrangements.” A student nurse has recently commenced her elderly secondment as part of her training and stated that staff had made feel welcome and the aims of the home had been explained in detail to her. An agency nurse who undertakes regular shifts at the home was complimentary regarding the manager’s knowledge of dementia care. Inspection of records indicated that fire prevention equipment was tested ‘in house’ and by the home’s qualified engineer. Records indicated however that no weekly tests of the fire alarms have been conducted since April 2005 and there appeared to be some confusion as to the recording of this information. The home’s maintenance man checked the fire alarms during the inspection and these were found to be satisfactory. This check must be undertaken each week. The fire log book evidenced a fire drill in 2003 and therefore it is recommended the home refer to the guidelines given by the fire service department regarding the frequency of fire drills for care homes. Advice should also be sought regarding the closure of fire doors, as some were wedged open. Fire door must be kept shut. Fire awareness training is required for staff and it was agreed this would be arranged this month. Certificates and maintenance contracts for equipment in the home for gas, electric, lift, manual handling aids and electrical appliances were in date. Abbendon Nursing Home F53 F03 S17215 Abbendon V226415 160505 Stage 4.doc Version 1.30 Page 22 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 2 3 STAFFING Standard No Score 27 3 28 x 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 3 3 x x x x x 2 Abbendon Nursing Home F53 F03 S17215 Abbendon V226415 160505 Stage 4.doc Version 1.30 Page 23 NO Are there any outstanding requirements from the last inspection? 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 9 Regulation 13 Requirement The manager must ensure all medication is accurately recorded on receipt in to the home The manager must ensure an accurate record is made of all medicine administration including, wound care dressings, external preparations and meal replacement drinks The manager must ensure records are maintained of hot water to the home to ensure it is delivered to a safe temperatue The manager must ensure all staff receive mandatory training including, manual handling, first aid, food hygiene and infection control. Records must be kept of training The manager must ensure all new staff receive an induction within the first 6 weeks of employment. Records must be kept of induction training The manager must ensure staff receive fire awareness training a minimum of twice a year Fire door must be kept shut Timescale for action 01.07.05 2. 9 13 01.07.05 3. 25 13 01.08.05 4. 30 18 & 19 01.08.05 5. 30 18 & 19 01.07.05 6. 7. 38 38 23 23 01.07.05 01.07.05 Abbendon Nursing Home F53 F03 S17215 Abbendon V226415 160505 Stage 4.doc Version 1.30 Page 24 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 27 21 38 Good Practice Recommendations Consideration should be given to the appointment of a kitchen assistant Staff should record the temperature of the hot water prior to bathing residents Guidance should be sort from the fire safety department regarding closure of fire doors and the frequency of fire drills Abbendon Nursing Home F53 F03 S17215 Abbendon V226415 160505 Stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection Burlington House, South Wing 2nd Floor, Crosby Road North Waterloo Liverpool L22 0LG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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