Inspection on 03/06/08 for Abbey Dean

This inspection was carried out on 3rd June 2008.

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 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

Abbey Dean 22/05/09

Abbey Dean 21/05/09

Abbey Dean 09/02/09

Abbey Dean 26/05/06

Abbey Dean 04/01/06

Abbey Dean 19/07/05

Abbey Dean 07/02/05

Abbey Dean 02/07/04

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Abbey Dean 102 Barnham Road Barnham Chichester West Sussex PO22 0EW Lead Inspector Val Sevier Unannounced Inspection 10:30 3rd June 2008 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 Abbey Dean DS0000014338.V365168.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. Abbey Dean DS0000014338.V365168.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbey Dean Address 102 Barnham Road Barnham Chichester West Sussex PO22 0EW 01243 554535 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) Mrs Laramie Dean Mr David Geoffrey Dean Mrs Laramie Dean Care Home 14 Category(ies) of Old age, not falling within any other category registration, with number (14) of places Abbey Dean DS0000014338.V365168.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th May 2006 Brief Description of the Service: Abbey Dean is registered to provide personal care for up to fourteen people over the age of sixty-five years (category OP). The building is semi-detached and the accommodation is provided on the ground and first floor. The accommodation is single rooms that have en-suite facilities with a toilet and hand basin. A passenger lift is provided to the first floor. There is a lounge, conservatory and dining room on the ground floor. There are well kept gardens with lawns and walkways that are accessible. Mr and Mrs Dean own Abbey Dean. Mrs Dean is the registered manager responsible for the day-to-day management of the establishment. The fees for the home at the time of the visit were £495 per week. Abbey Dean DS0000014338.V365168.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service 0 star. This means the people that use this service experience poor quality outcomes. The purpose of the inspection was to assess how well the home is doing in meeting the key National Minimum Standards and Regulations. The findings of this report are based on several different sources of evidence. These included: the Annual Quality Assurance Assessment (AQAA) completed by the home, and an unannounced visit to the home, which was carried out on the 3rd June 2008, during which we were able to have discussions with staff and have interaction with some people who use the service. During the visit we looked around the inside and outside of the home, which included a sample of bedrooms and bathrooms. Staff and care records were sampled and in addition to speaking with staff and people who use the service, their day-to-day interaction was observed. All regulatory activity since the last inspection was reviewed and taken into account including notifications sent to the Commission for Social Care Inspection. We also sent several surveys for completion by those that use the service and other professionals, at the time of writing this report we have not received any back although the home said that they had been given out and some had been completed. What the service does well: The home welcomes people who will use the service and their families or representatives, to visit the home and look at the facilities of the home. The manager seeks information from external healthcare professionals as part of the assessment where necessary, to ensure that the home is able to meet assessed needs. Staff treat people who live at the home with respect; they share their companionship and give support sensitively. Daily routines in the home were flexible and people who use the service are encouraged to make choices for themselves and exercise personal autonomy as far as was reasonably possible. Abbey Dean DS0000014338.V365168.R01.S.doc Version 5.2 Page 6 People who live at the home were positive about the food that the home provided and were pleased with the activities in which they could participate and the condition of the accommodation that they occupied. What has improved since the last inspection? What they could do better: Care plans must detail the care and support needs for individuals where support has been identified so that staff are aware what they need to do for people who live at the home. Where risk assessments have been carried out and a risk has been identified there must be a record of action to be taken to minimise the risk for people who live at the home as far as possible. Medication records must indicate when a medication has been given or reason why it has been omitted. Medication prescribed for one individual must not be transferred to another individual. The procedure for recruiting staff must ensure that there are CRB, POVA First checks carried before employment commences, to protect those people that live at the home. Abbey Dean DS0000014338.V365168.R01.S.doc Version 5.2 Page 7 There must be a record of accidents that have occurred at the home. Staff must receive regular training in fire safety to protect those people that live at the home. Fire safety equipment must be tested regularly to protect those people that live at the home. 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. Abbey Dean DS0000014338.V365168.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Abbey Dean DS0000014338.V365168.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People that use the service can feel assured that their needs will be assessed and that the home has an understanding of their needs using the assessment process, which involves others as needed. However the current assessment record would prove more beneficial to the assessment and care plan process for the individual if there is a record of the information by which to make a decision as to whether the home can meet identified needs. EVIDENCE: We received the AQAA for the home, which stated that: “We make them feel happy and secure. We have an up to date service user guide, new clients have a full assessment and care plan. They can agree a trial period. We have updated our service user guide to include statement of purpose as well as all other relevant information”. It was seen in the ‘how we have improved in the last twelve months that the home has updated the service user guide to include statement of purpose as Abbey Dean DS0000014338.V365168.R01.S.doc Version 5.2 Page 10 well as all other relevant information. Mrs Dean the registered manager carries out the assessment and when people move in they are given an information pack related to them and the room they are moving into. The assessment includes the following areas: a contact names sheet, personal details, medical details for example doctor and health issues; social information for example previous occupation, children and social history; allergies and next of kin. There are also several risk assessments completed for example falls, nutrition and moving and handling. Abbey Dean DS0000014338.V365168.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The records and systems within the home do not always ensure that the personal and healthcare needs of people who use the service are met safely and effectively. People who use the service are at risk regarding the administration of medication with records not being maintained and medication being reassigned. Staff working practice helped to ensure that the privacy and dignity of people who use the service is promoted. EVIDENCE: The home’s AQAA told us that: “Every client has an individual personal health and psycho-social needs plan. We respond pro actively to any changes. They pursue many diverse liesure interests. They have a choice of health and dental care. We take them to all appointments in our own Mini-bus”. Abbey Dean DS0000014338.V365168.R01.S.doc Version 5.2 Page 12 We sampled three care plans of people who use the service that had moved to the home since the last visit. The care plans sampled were being used in conjunction with medication records and other health-monitoring tools that are used as part of the care planning for individuals. The care plans are pre typed with headings of possible care needs for example: mobility and dexterity, diet and communication. There is a second sheet of paper with a personal profile with areas to consider for example: personality and goals, religion and cultural activities and significant events. One individual’s care plan gave information for staff: “walks with a Zimmer needs prompting and some input from 1 carer”. The cognitive and psychosocial needs was blank. The action plan at the end of this page stated: “maintain and improve current level of cognitive and physical ability in a safe and secure environment”. We could not see how staff would do this. For this first individual we saw that there were risks assessments for daily living, falls, behaviour and pressure areas, there was no information of where a risk had been identified that action had been taken to lessen the risk. Examples for the second individual whose care plan we saw included: “skin and pressure areas intact, apply diprobase and support hose if legs not sore. Minimal short term memory loss, express needs easily, likes to eat lunch in room”. It was seen that in addition to the four risk assessment already mentioned above, that there was also a physical health assessment and mental assessment. There was no information as to what staff should do to lessen any risk identified or of what action to take regarding these assessments. The third individual’s plan indicated that there was “occasional aggression” which was “easily managed” we could not see information for staff on how they would do this. The cognitive and psychosocial part of the plan stated: “short term memory loss, independent, enjoys paper and trips in minibus, and lunch with family”. There was also a physical health assessment and mental assessment. There was no information as to what staff should do to lessen any risk identified or of what action to take regarding these assessments. It was seen that for two of the individuals whose care plans we saw that a nutritional screening form had been completed however there was no action for staff to address any needs identified from this assessment. We were shown a separate file which staff complete which is a 24hour care record of daily events we noted that it had information about baths, peoples behaviour and falls. We saw that one individual had had a fall on 1st June 2008; we found the record in the accident book. We also found another entry in the accident book for this individual dated 22nd May 2008 the falls had both occurred between 12 midnight and 1 o’clock in the morning. We asked for the previous accident books so that we cold track any previous falls for this individual the manager found two other books, the last entry in the previous Abbey Dean DS0000014338.V365168.R01.S.doc Version 5.2 Page 13 book to the one for May 2008 was November 2007, there was a gap of five months. There was no information in the care plan on how staff could reduce the risk of falls. Although the manager said that some night staff spend the night in the room with the individual to help prevent these falls. We were able to speak with five staff members and we asked about the care plans and information that they had about the needs of individuals who live at the home. They commented that they knew about peoples needs and information was given verbally or was in the care plans. The home had written policies and procedures concerned with the management and administration of medication. Medication was kept in locked and secured cupboards in the staff sleeping in room. We saw a signature list of staff that give medication. There were homely remedies instructions signed by two doctors. We saw that one individual has been assessed and self medicates. The Medication Administration Record sheets (MAR), which we saw were started on the 12th May 2008. We noted that there were ‘?’ in some spaces and not a signature we asked who ordered and checked the medication the manager Mrs Dean said that she did however she had not put these question marks in. She thought someone had queried the gap. It was seen that there were 40 question marks and 28 spaces where nothing had been recorded. It was seen that many of the gaps or question marks were on particular days such as Saturdays and the pm of the day, the manager said that she would look into who this was and that there was less support at the weekends. We saw that a box of Furosemide 20mg one daily dated 12/4/08 had the name crossed out in blue pen and another name written on it. There was a box of Furosemide 40 mg for a different person and this name had also been crossed out and another name written on it. The individual whose name was written on it did have a MAR record with these medications on it. We asked who had done this the manager said she had. We saw a box of Omprazole 20mg 1 daily dated 14/3/08 the name had also been crossed out in blue pen no new name had been written, we found that there were two people who have been prescribed this medication at this dosage and that the medication was in the monitored dosage blister packs. We have asked the manager to write to us within seven days of the visit to tell us how this occurred and what the changes to this practice will be. Staff were observed speaking and assisting individuals with dignity and respect. It had been seen on care plans that the preferred choice of name had been recorded and staff were heard to speak to individuals by the name they wished. People we spoke with at the home had high praise for the staff and Abbey Dean DS0000014338.V365168.R01.S.doc Version 5.2 Page 14 management saying that nothing was too much for them and that they felt well cared for. Abbey Dean DS0000014338.V365168.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, & 15 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service participate in activities appropriate to their age, peer group and cultural beliefs as part of the local community. Dietary needs are well catered for with a balance and varied selection of food available that meets individual dietary requirements and choices. EVIDENCE: The AQAA for the home stated that “We have beetle drives, musical afternoons, craft and arts afternoons which many choose to join in or not. Visitors are always welcome and offered suitable refreshment. Meals are varied and new menues often tried, clients are invited to feed back and to contribute to choices of meals. Flexible routines to fit all clients. They are encouraged to maintain religious or day clubs and outside social activities. They are encouraged to maintain family contact”. We saw that each individal had in their room a list of events that are planned for the month ahead, we saw that a BBQ was planned for the day after the visit although this depended on the weather, there were also entertainers Abbey Dean DS0000014338.V365168.R01.S.doc Version 5.2 Page 16 booked in as well as mini bus trips and a cream tea to which relatives have been invited. There is no planned menu for the home, the cook said that she speaks with people who live at the home a week at a time to plan the following weeks menu, asking what they would like. If on the day any individual has changed their mind she will offer something else. There are diabetics at the home whose diabetes is managed through their diet; the cook and manager said that they received the same food, as it was important all people received a nutritionally balanced meal. People we spoke with who were able to comment said that they liked the food. Abbey Dean DS0000014338.V365168.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 & 18 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are protected through the open complaints process and the staff’s knowledge and understanding of safeguarding and protection issues. EVIDENCE: The homes complaints procedure was seen to be available in the information given to people who use the service. There have been no complaints received by the commission. The manager advised that the home promotes an open door approach to relatives and people who use the service, to help resolve complaints and issues effectively. The home uses West Sussex safeguarding adult policy and staff were seen to have training in adult protection as part of their induction as well as yearly updates. The AQAA for the home stated that: “We have a formal complaints procedure, we have a complaints record book. All staff are trained in preventing elderly abuse. We have a whistleblowing policy”. The home was advised that the complaints procedure would need to have the commissions contact details changed. Abbey Dean DS0000014338.V365168.R01.S.doc Version 5.2 Page 18 We saw on staff files we sampled that training had taken place last year in safeguarding adults. Staff we spoke with said that they would report anything they were unhappy with to the owners. We asked if there was a difficulty at that level where would they go, some said to the administrator others said they would seek guidance outside of the home from social services or the commission. Abbey Dean DS0000014338.V365168.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 & 26 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service have a pleasant and homely environment to live in which also has had adaptations to meet individual needs. EVIDENCE: We looked around some of the home and we were able to see communal areas such as the dining room, lounge, bedrooms and bathrooms. The garden is accessible with wheelchairs. People who live at the home are encouraged to furnish the room with personal belongings such as furniture and pictures, to make it feel like home. Abbey Dean is situated in its own large, well kept grounds. The home was seen to be very clean throughout, we noted a strong malodour on entering the home coming from one room, when we walked around the home later there was an odour of freshening spray. When we walked about the home we saw Abbey Dean DS0000014338.V365168.R01.S.doc Version 5.2 Page 20 that rooms are centrally heated, all radiators and pipe work are covered. Windows are fitted with restrictors where necessary and emergency lighting is provided throughout the home. The windows at the front of the home have been replaced since the last visit. Laundry facilities are sited away from areas where food is prepared and stored. Policies and procedures were seen to be in place regarding the control of infection. The AQAA for the home stated: “Abbey Dean is very clean and safe and well maintained indoors and outside. The garden is designed to enable clients to walk a circuit in safety. There are seats in appropriate areas, providing sun and shade. Clients rooms are personalised and arranged to suit their needs. All rooms are ensuite. Specialist equipment is quickly accessed should it be required. Clients are able to control the temperature of their rooms by individual thermostatic valves”. Abbey Dean DS0000014338.V365168.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): 27, 28, 29 & 30 People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff have received the mandatory training that is expected each year, however it was not clear that staff have received training to meet all the needs of people who use the service. The lack of checks in the current recruitment process places people who use the service at risk. EVIDENCE: The staffing structure at the home consists of: the owners one of whom is the registered manager, support workers, kitchen staff, and housekeeping. There are two night staff one awake and one asleep. Other health care professionals support the team from outside the home as needed. Staff spoken with on the day of inspection indicated that they were aware of the needs of the people who live at the home. There was evidence that staff have received training in mandatory areas such as food hygiene, first aid and manual handling, health and safety and safeguarding adults. The AQAA for the home stated that: “The staff who work the most hours are either NVQ or a trained nurse. All staff require two references and CRB check Abbey Dean DS0000014338.V365168.R01.S.doc Version 5.2 Page 22 before they work. All have a supervised induction shift. We are, in the mornings, at least one staff member above the requirement”. Staff we spoke with on the day who had started work at the home since the last visit said that they had worked at the home whilst working their notice in their previous job, to gain insight into the workings of Abbey Dean. We met a member of staff who was an apprentice working at the home and doing her NVQ 2. It was seen in the fire records book that 7 of the 16 staff members had had a quiz about fire safety on 14th April 2008 at the staff meeting. The remaining staff last had training in fire safety in October and November 2007. We looked at two files of staff that had joined the home since our last visit and who had worked shifts at the home in the last month. We found that there was an application form and two references; there was no evidence that a POVA First and Criminal Records Bureau check had been requested. The manager stated that the administrator requested these checks. When asked the person said that they had not requested these two checks for new staff as the body they use to request these checks from the CRB no longer do this. We were asked to give a name of someone who would do this, the home were advised that this is not our role and to access the CRB website. The manager did not comment on the two staff who had been working as bank staff at the home with no checks. A comment was made that one of the staff was known to the home having worked there previously but they had left the home for 18 months before they returned. Abbey Dean DS0000014338.V365168.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 & 38 People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The lack of risk assessments and information in the care plans; current medication administration and recording, and recruitment practices place people who use the service at risk. There are however other systems and procedures in place, which monitor and maintain the quality of the service provided and which, promote the safety and welfare of those living and working in the home. EVIDENCE: The manager is a nurse although she is not employed as a nurse at the home, which provides personal care. She also has a Masters Degree in Business Studies. She has been managing the service at Abbey Dean since the home Abbey Dean DS0000014338.V365168.R01.S.doc Version 5.2 Page 24 opened in 1991. Residents spoken to during the inspection praised the staff and the owners for their support and care. Two areas of concern for example recruitment and fire safety have been delegated to other people by the manager. It would appear that these areas have not then been checked to ensure that the manager’s instructions have been carried out. The home has no formal quality assurance/monitoring system in place. We were told that the views of people who use the service are sought in regard in regard to the running of the home. People at the home who were able to comment said that regular residents meeting are held. Mrs Dean said on the day of the visit that she is considering using the AQAA we send yearly as the basis of her quality assurance monitoring system. There is a clear management structure with policy & procedures reviewed as necessary. There were a range of written policies and procedures available for staff to refer to as guidance and to inform their practice. These included the following: • Admission, discharge and transfer of residents • Human Rights • Confidentiality and access to personal records • Abuse of the person • Drug administration • Self administration of medication • Infection control • Complaints procedure • Whistle-blowing • Sexuality • Health and safety at work The AQAA started that: ”Regular training and supervision takes place. Staff are motivated and loyal protecting the health and welfare of clients. Our administration has regard and sensitivity for probity. Residents families find our financial system sound. We have employed a very experienced NVQ3 trained carer who is efficent, clients feel safe and less experienced staff feel supported. We have developed a more efficient petty cash system”. Individuals control their own money wherever possible. In the event they are unable to, family or solicitors take control of their finances. The home does hold personal spending money for some people. A record is kept of all transactions made, copies are available for relatives and individuals to see. As noted earlier in the report there are accident report books that have been completed at the home, there is a gap between November 2007 and May 2008. Abbey Dean DS0000014338.V365168.R01.S.doc Version 5.2 Page 25 As noted in the previous section of this report fire training has taken place but not all staff have received an update every six months. We looked at the records for testing and monitoring the fire safety equipment, we saw that the last recorded test of the system was 3rd Aril 2008, the emergency lights had last been checked September 2007 and April 2008. An outside contractor had checked the system in April 2008. The owners stated that they had delegated the checking of the fire system to a senior member of staff. Abbey Dean DS0000014338.V365168.R01.S.doc Version 5.2 Page 26 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X 3 X X 1 Abbey Dean DS0000014338.V365168.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 Sch 3 (1)(b) 17 (1)(a) Sch 3 13 (4) (b)(c) Requirement People who use the service must have clear individual care plans describing the support that staff give to meet identified needs A record of accidents affecting the well being of people who use the service must be maintained. Where it has been identified that people who use the service are at risk from falls, a risk assessment must be put in place to lessen those risks. Medication administration records must show what medication has been a given or state reason why it has been omitted. Medication that is prescribed for one individual must not be transferred and used for another individual, by the homes staff. A thorough recruitment of staff must include, CRB and POVA First checks to protect people who use the service. All staff must receive regular fire safety training. Fire safety equipment and lighting must be tested on a DS0000014338.V365168.R01.S.doc Timescale for action 01/07/08 2 3 OP8 OP8 01/07/08 01/07/08 4 OP9 13 (2) 01/07/08 5 OP9 13(2) 10/06/08 6 OP29 19 Sch 2 (5)(6)(7) 23 (4) (d) 23 (4) (c) 01/07/08 7 8 OP38 OP38 01/07/08 01/07/08 Abbey Dean Version 5.2 Page 28 regular basis to ensure that there are no faults and a record must be kept of these tests. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Abbey Dean DS0000014338.V365168.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Abbey Dean DS0000014338.V365168.R01.S.doc Version 5.2 Page 30 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!