Inspection on 19/04/05 for Abbey Chase Residential and Nursing Home Ltd

This inspection was carried out on 19th April 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Abbey Chase Residential and... 10/08/06

Abbey Chase Residential and... 27/10/05

Abbey Chase Residential and... 19/10/04

Abbey Chase Residential and... 17/05/04

Similar services:

The Shelley

Thorndene

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

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

CARE HOMES FOR OLDER PEOPLE Abbey Chase Abbey Chase House Bridge Road Chertsey KT16 8JW Lead Inspector Ms S Magnier Unannounced 19 April 2005 07.00 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. Abbey Chase H58_s17587_Abbey Chase_v219102_180405 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Abbey Chase Address Abbey Chase House, Bridge Road, Chertsey, Surrey, KT16 8JW 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) 01932 569768 01932 571702 ABBEYCHASE@HOTMAIL.COM Abbey Chase Residential and Nursing Homes Limited Mrs Jean Short CRH Care Home 62 Category(ies) of DE(E) Dementia - Over 65 registration, with number OP Old age of places PD(E) Physical disability - Over 65 Abbey Chase H58_s17587_Abbey Chase_v219102_180405 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: 1. Up to two of the older people accommodated may be in category PD(E), people with a physical disability. 2. People requiring Nursing Care may be admitted to the home from the age of 60 years. Up to 60 persons may receive Nursing care. 3. Up to five named people accomodated may be in catergory DE(E), older people with Dementia. Date of last inspection 19 October 2004 Brief Description of the Service: Abbey Chase Care Home is privately owned and operated by Abbey Chase Residential and Nursing Homes Limited. Nursing care for up to sixty older people,personal care for two older persons with a physical disability and care for four named persons with dementia is offered in premises situated next to the Thames in a rural part of Chertsey. Accomodation is provided in 52 single and five shared rooms. The gardens are well maintained and are accessible to the residents if they choose to sit and enjoy the scenery and life on the river. There are arrangements for disabilty access which include ramps and pathways. There is a pleasant shaded and safe central courtyard which can be enjoyed both by residets in the ample seating areas and also viewed by residents from bedrooms. The care home also provides ample car parkig facilities. Abbey Chase H58_s17587_Abbey Chase_v219102_180405 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home was visited at 07.00 by two inspectors and the unannounced inspection lasted for 7 hours. The home and was well run and managed efficiently and effectively. The general atmosphere of the home was calm and orderly. Care plans and risk assessments for the residents were seen and also staff files related to recruitment. Residents and staff were spoken to and comment cards left at the home for people to give their feedback to the Commission for Social Care Inspection about the home. The Registered Provider and Registered Manager must obtain a copy of the Care Homes Regulations 2000 (as amended) 2001 to which the requirements in the report are made. What the service does well: What has improved since the last inspection? What they could do better: The home could: • Continue to improve and develop the care plans for each resident. • Review the serving of breakfasts for the frail residents in the home. • Seek to employ a full time activities coordinator. • Seek to employ a full time training Manager. • Review the current recruitment and selection process and documentation used. Abbey Chase H58_s17587_Abbey Chase_v219102_180405 Stage 4.doc Version 1.20 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Abbey Chase H58_s17587_Abbey Chase_v219102_180405 Stage 4.doc Version 1.20 Page 7 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 Abbey Chase H58_s17587_Abbey Chase_v219102_180405 Stage 4.doc Version 1.20 Page 8 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) 1,2,3,4. The Registered Manager needs to review the homes admission and assessment procedure to ensure that residents needs are met and that it is compliant with the Care Homes Regulations 2000(as amended) 2001. EVIDENCE: The home has a Statement of purpose and a resident’s guide. Both must be updated and reviewed to meet the needs of the resident’s e.g. large print and copies sent to CSCI local Eashing office. The care plans seen by the inspectors included a full needs assessment prior to moving into the home, however there was no written contract of the terms and conditions of stay in the home. Whilst speaking with the Manager it was evident that the home is currently supporting a resident who does not comply with the homes category of registration. The home has sought support and assistance from the local Social Services department and the family of the resident to find appropriate alternative accommodation within a specified timescale. Abbey Chase H58_s17587_Abbey Chase_v219102_180405 Stage 4.doc Version 1.20 Page 9 It is recommended that the home forward to the CSCI local Eashing office a list of all residents in the home and the confirmed diagnosis of the resident’s in order to ensure that the home is working within the current category of registration. Additionally it is recommended that the home have a written checklist situated in the front of each residents care plan to be completed when the resident has received the relevant documentation to meet the standards on admission to the home. A comment card received from a resident explained their views of the home ‘ The immediate impression was very welcoming and I am very sure from the first moment on meeting happy staff that I would be happy here. I have been here a month now and am even more impressed.’ Abbey Chase H58_s17587_Abbey Chase_v219102_180405 Stage 4.doc Version 1.20 Page 10 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) 7,8,9,11,10, The Registered Manager and staff continue to actively develop the residents care plans, which have nearly been completed throughout the whole of the home. Once this is done the needs of the residents will be fully met, documented and should be reviewed monthly. A review of medication handling which was undertaken by a CSCI pharmacist inspector, concluded that the systems for the administration of medication whilst safe could be improved. EVIDENCE: The care plans seen contain a colour coded system for staff to work with and include a specimen signature sheet for staff to sign, a resident information record, medical history, nursing care plan for individual needs, daily notes and evaluation and care plan review sheet. The care plans covered aspects such as: • Communication. • Personal and health care. • Risk assessments. • Nutrition. • Social Care and Activities. Abbey Chase H58_s17587_Abbey Chase_v219102_180405 Stage 4.doc Version 1.20 Page 11 The care plans sampled identified several nursing assessments that had not been signed by the resident or their representative and no photo to identify the resident. A recommendation has been made that residents who require nursing, residential and respite care are identified to visiting professionals in order that they have an initial indicator of the residents care. Several written records showed thoughtful and sensitive approaches to residents, which was viewed as good practice. Several residents spoken with commented that ‘ Their very kind to me here’ ‘I feel privileged to be here’. Staff knocked on resident’s doors before entering their rooms and residents were addressed in a respectful and appropriate way. The CSCI Pharmacy Inspector visited the care home on 20.4.05 and the evidence obtained is as follows: Medication stocks and records were sampled and showed that service users were receiving their medication as intended by their doctors. The records of administration were generally good but when medication was not administered the reason why was not clearly recorded. Also when a variable dose was prescribed the actual dose administered was not being recorded consistently throughout the home. At this time no service users were administering their own medications. Medication was stored securely for the protection of service users. Controlled Drugs were stored in a cupboard, which was not fixed correctly to the wall. Abbey Chase H58_s17587_Abbey Chase_v219102_180405 Stage 4.doc Version 1.20 Page 12 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) 12,13,14,15 The comments made from the residents about their choices and lifestyle in the home was positive and all spoke highly of the home however the arrangements for resident’s activities could be improved. In addition the standard relating to meal provision for frailer residents was concerning and required urgent attention. EVIDENCE: The receptionist who works full time also provides the activities in the home she gives each resident a questionnaire each week to let the residents know what activities are on offer and they can select what they would like to attend and a record of the attendance is kept. On the day of inspection the organisation of a reminiscence project for D Day was being arranged which included a victory party and discussions on what food to prepare and have available for the day. Other activities include walks in the garden, a port afternoon with a quiz, and Bingo. Additionally community links are maintained with a pat dog visiting every other week and church services and communion services held regularly. It has been noted that on previous CSCI inspections requirements have been made and not met that the home must review the activity provision to residents with physical disabilities, sensory impairment, dementia and other Abbey Chase H58_s17587_Abbey Chase_v219102_180405 Stage 4.doc Version 1.20 Page 13 cognitive impairment. Additionally, that staff providing and or coordinating activities have received appropriate training. In discussion with the Registered Provider and Manager the inspectors have recommended that a review of the current situation of the homes full time receptionist providing activities to the residents be reviewed. One resident said ‘they take us out Christmas shopping’ On arrival to the home at 07.00 one inspector observed the serving of breakfast. It was noted that trays were attractively prepared yet four trays contained bowls of porridge, which were left on the trays for over five minutes and served to the residents. One resident said that the porridge was cold and couldn’t eat it and staff, were requested by the inspector to offer a hot bowl of porridge and a hot cup of tea, which the resident was very grateful for. The concerns regarding the serving of the breakfasts in this manner for the more, frail resident was discussed with the Registered Provider and Manager. Requirements have been made that this manner of serving breakfasts is ceased. Additionally it was noted that these residents were not offered napkins or saucers for their cups of tea and requirements have been made that adequate and appropriate crockery is available to residents and their dignity maintained. For several other residents in the home the comments regarding the meal times were positive ‘breakfasts are good’ ‘The food is good’ ‘I talk and laugh together at lunch time with my friends’. Some residents offered suggestions ‘Id like to have pasta’ The homes chef has sole responsibility for the meals of the home and the cleaning schedule; food temperatures and fridge freezer temperature records were seen by the inspectors, which were well documented. A full inspection of the catering and kitchen area will be done at the CSCI Announced Inspection. The serving of the midday meal was observed and reflected dignity and respect for the residents. Meals were served in a professional and calm manner and staff, were sensitively available to residents who needed extra support. Several residents were enjoying wine with their meal and menus were available and residents knew what meals to expect. The meals served were hot and the dessert attractive and colourful. Asked about choice in the home and having visitors several residents comments included ‘after breakfast I’m going to get back into bed’ and ‘I think I have everything I need but I don’t know what I need’ and ‘My boy comes every night’ ‘my granddaughter visited and took me out shopping’. ‘ The surrounding garden is delightful and visitors are free to come and go’. ‘I’m happy here, my family visit regularly but they are busy with their own lives’ Abbey Chase H58_s17587_Abbey Chase_v219102_180405 Stage 4.doc Version 1.20 Page 14 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 The complaints policy and procedure needs to be reviewed and conclusions to any complaints documented clearly to demonstrate that the complaint has been fully investigated. EVIDENCE: Prior to the unannounced inspection a visit to the home had been made following a complaint, which was subsequently referred to the local authority under the Surrey Multi Agency Protection of Vulnerable Adults procedure. Requirements were made under the Care Homes Regulations 2000 (as amended) 2001 that the home update and review the care planning and documentation of the daily records which was discussed with the Manager during the unannounced inspection and an extended timescale agreed of 2.5.05. Discussion with the Manager on a previous visit had identified that the home must document the conclusions of complaints, as those seen had not been concluded with the complainant. The home is currently investigating one complaint and will inform CSCI of the outcome. Abbey Chase H58_s17587_Abbey Chase_v219102_180405 Stage 4.doc Version 1.20 Page 15 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) 19,20,21,22,23,24,25,26 The home is clean and generally well maintained. The residents spoke highly of their private and communal accommodation and their freedom to move around the home and grounds. EVIDENCE: The home is generally clean and bright and well maintained both internally and externally. One resident said ‘they are very kind to me here it’s a wonderful place and its clean.’ Resident’s rooms are personalised with resident’s own furniture and fittings, televisions, radios, C.D players and daily papers are delivered. Residents are able to move around the home freely and visitors are free to come and go as they wish. One resident said ‘I like it here’; ‘in the morning I put all the covers out’; ‘it has altered greatly’; ‘I pour my own tea out’. The bathrooms and toilets were clean and spacious and portable hoists in the home had been recently serviced. Abbey Chase H58_s17587_Abbey Chase_v219102_180405 Stage 4.doc Version 1.20 Page 16 One resident bedroom had an offensive odour and a requirement has been made that this is rectified. One resident said that they felt ‘There’s a lot for (the housekeeper) to do’. During the inspection it was noted that a resident was using a wheelchair to move around the home and no footplates were attached to the wheelchair. The Manager told the inspectors that the resident preferred to use the chair in this way and a requirement has been made that this is risk assessed and documented in the residents care plan to ensure their safety and also the staff. Abbey Chase H58_s17587_Abbey Chase_v219102_180405 Stage 4.doc Version 1.20 Page 17 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) 27,29,30 The home has a hardworking staff team who demonstrated a commitment and professionalism to the residents. Staff recruitment and training records identified certain gaps and requirements have been made that these are met in order to ensure the safety and welfare of residents. EVIDENCE: Several resident’s spoken with said of the staff: • ‘they look after me well’; • ‘I think the staff are excellent and I have no trouble with them at all’; • ‘I think they are sometimes short staffed but it depends who you talk to’; • ‘I can’t fault the service, everyone is kind’; • ‘Everything goes like clockwork.’ • ‘Staff too bossy I want things my way’. • ‘We could do with more senior staff at the weekend for surveillance and also in the dining room as sometimes of a tea time there’s only one or two’; • ‘they could do with a mobile worker, someone who could cover when someone’s off sick’. One resident wrote to the inspector to say, ‘Happy staff working as a team dictates so much about the home. This one is unique, no grumbles, no complaints just quiet efficiency’. Abbey Chase H58_s17587_Abbey Chase_v219102_180405 Stage 4.doc Version 1.20 Page 18 RECRUITMENT Several staff files seen identified some shortfalls in the recruitment and selection of staff. The application form currently being used by the home needs to be reviewed and updated, staff must provide a recent photograph, full employment histories and gaps in employment must be explored by the Manager. The applicant reference form could be improved, as the current form does not include name or designation of referee. It was noted that previous requirements have been made with regard to the recruitment and selection of staff and also includes the staffing files for the chiropodist, hairdresser and people of the clergy. TRAINING Staff files seen contained evidence of the home providing an induction programme and training certificates which included current Infection control, Fire safety, Dementia awareness, copy of the National Minimum Standards for Older people, Care and Control of medicines, Protection of Vulnerable Adults Caring for people with strokes and Healthcare Law. There was no evidence that staff had received Moving and Handling training and a requirement has been made that this is completed by all staff in order to ensure that safety and wellbeing of the residents. Following discussion with the inspectors the Registered Manager the Senior and Registered Manager identified that a training coordinator needs to be appointed and a recommendation has been made that the Responsible Individual pursue the contacts already made in view to this appointment in order to provide the residents with leisure and therapeutic activities. The Manager has been proactive in organising a Dementia training programme, as required from the last inspection, and will be seeking the services of Nescott College to facilitate this training in the near future. A further requirement has been made that this is implemented, as this has not been met from the previous inspection of 18.2.03 and 17.8.04 and 19.12.04. Abbey Chase H58_s17587_Abbey Chase_v219102_180405 Stage 4.doc Version 1.20 Page 19 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, 33, 38 Comments received from residents demonstrated that they are consulted regarding the running of the home and felt included. Arrangements to ensure the health and safety of residents and staff needs to be improved. EVIDENCE: During the inspection the following health and safety hazards were identified and requirements made that these be met within the timescales identified: • • • Wheelchair footrest plates were in a resident’s room on the floor. A Fire extinguisher needs to be re sited as it was not secure on wall mount. An electric lead from an air mattress was observed trailing across the floor and was a hazard to residents and staff. H58_s17587_Abbey Chase_v219102_180405 Stage 4.doc Version 1.20 Page 20 Abbey Chase • • • • • For one resident who required specialist feeding has empty boxes left in their room. This did not reflect a homely environment and must be discarded. Black plastic tape had been secured around a portable hoist cable: this must be removed to ensure that the cable underneath is not damaged and arrangements made to replace it if necessary. The lock on the sluice room door on the top floor requires replacing, as it was broken. In the staff rest area no soap was available for staff to wash their hands. It was observed that a door was wedged open with a footstool leading from the lounge dining area on top floor presenting a fire safety hazard. In discussion with the Manager a requirement has been made that more discreet signage in residents rooms regarding control of infection has been made to reflect residents rights to confidentiality. Abbey Chase H58_s17587_Abbey Chase_v219102_180405 Stage 4.doc Version 1.20 Page 21 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. Where there is no score against a standard it has not been looked at during this inspection. 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 2 2 3 2 x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 3 15 1 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 2 STAFFING Standard No Score 27 3 28 x 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x x 3 3 3 x x x x 2 Abbey Chase H58_s17587_Abbey Chase_v219102_180405 Stage 4.doc Version 1.20 Page 22 YES 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 1 Regulation 4.(1)(a-c ) Schedule 1 5.(1)(a-f) Requirement The Registerd Provider must update and review the current Statement of Purpose, a copy of which must be forwarded to CSCI local Eashing office,. The Registered Provider must update and review the service users guide a copy of which must be forwarded to CSCI local Eashing office. The Registered Provider and Manager must provide the residents with a written contract/statement of terms and conditions including fees, nursing and personal care and provision of food. The Registered Manager must ensure that all care plans are signed by the resident or their representative and a recent photograph of the resident is within their care plan. Complete and accurate records must be kept of all medication administered or not administered, together with the reasons for the nonadministration to service users. When variable doses of medication are prescribed a Timescale for action Immediate 20.4.05 2. 1 Immediate 20.4.05 3. 2 5.(3) 5A (1)(2)(3) (4)(5)(6) 19.5.05 4. 7 17.(1)(a) Schedule 3 19.5.05 5. 9 17.(1)(a) 18.5.05 Abbey Chase H58_s17587_Abbey Chase_v219102_180405 Stage 4.doc Version 1.20 Page 23 6. 9 13.(2) 7. 12 16.(2)(m) 8. 12 18.(1)(a)( c)(i) 9. 17 12.(4)(a) 10. 17 16.(2)(g)( i) 11. 22 4.(c record must be made of the actual dose administered to the service user. The Controlled Drugs cupboard must be correctly secured to a solid wall in order to comply with the Misuse of Drugs (Safe Custody) Regulations 1973. The Registered Provider and Manager must review the activity provision to residents with physical disabilities, sensory impairment, dementia and other cognitive impairment. Timescale of 19.10.04 not met. The Registered Manager must ensure that the staff providing and or coordinating activities have received appropriate training and are suitably qualified. Timescale of 19.4.05 not met. The Registered Manager must ensure that the preparation and serving of residents meals is conducted in a manner that respects the dignity of residents. The Registered Manager must ensure that sufficient appropriate crockery and cutlery is available to residents and meals are provided that are suitable, wholesome and nutrious to meet the needs and choice. The Registered Manager must ensure that all unnecessary risks to the health and saftey of residents is identified and as far as possible eliminated. The Registered Manager must ensure that all parts of the care home are free from offensive odours. The Registered Provider must not employ a person to work in 31.5 19.7.05 19.7.05 22.4.05 22.4.05 3.5.05 12. 26 16.(2)(k) 3.5.05 13. 29 7,9,& 19 Schedule 9.5.05 Page 24 Abbey Chase H58_s17587_Abbey Chase_v219102_180405 Stage 4.doc Version 1.20 2 14. 30 13.(5) 15. 30 18.(1)(a)! 8.(1)(c)(i) 16. 38 13.(a) 17. 38 12.(4)(a) the care home unless all the information and documents specified in paragraphs 1 -9 of Schedule 2 of the Care Homes Regulations (as amended) 2001. This includes people brought into the home to provide a service such as chiropodist, hairdresser and people of the clergy. Timescale of 19.10.04 not met. The Registered Manager must ensure that all staff receive Moving and Handling training to ensure that safety and well fare of the residents. The Registered Manager must arrange for all staff have specilaist training to meet the needs of residents with Dementia. The Registered Manager must ensure that all parts of the home to which residents have access are so far as reasonably practicable free from hazards to saftey. The Registered Manager must ensure that the care home is conducted in a manner which respects the privacy and dignity of resident. 19.7.05 19.7.05 19.5.05 22.4.05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 1 Good Practice Recommendations The Registered Manager should forward to the CSCI local Eashing office a list of all residents in the home and the the confirmed diagnosis of the residents in order to ensure that the home is working within the current category of registration. That in order to promote best practice the Home has a H58_s17587_Abbey Chase_v219102_180405 Stage 4.doc Version 1.20 Page 25 2. 1 Abbey Chase 3. 7 4. 9 5. 6. 12 12 written check list in the front of each residents care plan to be completed when the resident has received the relevant documentation, on admission to the home, to meet the standards. As the home supports residents who require nursing, residential and respite care this should be identified to visiting professionals that they have an initial indicator of the residents care. Where it is necessary to handwrite a medication administration record chart in the home, the member of staff writing the chart should sign the chart and a second carer check the entry for accuracy and then initials the chart. The home should seek to employ a full time activities coordinator. The home should seek to employ a full time training cordinator. Abbey Chase H58_s17587_Abbey Chase_v219102_180405 Stage 4.doc Version 1.20 Page 26 Commission for Social Care Inspection The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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. Extracts may not be used or reproduced without the express permission of CSCI Abbey Chase H58_s17587_Abbey Chase_v219102_180405 Stage 4.doc Version 1.20 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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