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Inspection on 24/05/06 for Abbey Grange Nursing Home

Also see our care home review for Abbey Grange Nursing Home for more information

This inspection was carried out on 24th May 2006.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The inspector observed that service users were well dressed in clean clothes and had received a good standard of personal care. Service users had visited the home for trial periods. The manager said that service users were only admitted once it had been determined that the home could meet their needs. Service users were encouraged and supported to maintain positive relationships with their families and friends. Staff handovers were taking place on a daily basis these meetings enabled the staff to discuss the current health needs of service users, to ensure that a consistent level of care could be offered. All service users attended a variety of social and leisure activities and these were based very much on the personal preferences of each individual. The home caters well for service users with physical disabilities. Feedback was being sought on a regular basis from relatives and service users. One relative spoke positively about the staff team and the care that her relative received. She commented that all the staff was "smashing". The service users finances were well managed.

What has improved since the last inspection?

The manager has worked hard in the last few weeks to introduce new systems to ensure the service is better managed. The responsible individual is visiting monthly and undertaking a check of issues relating to all aspects of the service. The manager has set up a system to monitor all accidents the service users have. The staff recruitment procedures now meet the required standards. There were some improvements in relation to the environment. Some bedrooms have been redecorated and the floorboards replaced in some parts of the home. New carpets and dining furniture has been purchased.

What the care home could do better:

Service users must only be admitted to the home on the basis of a full needs assessment. All service users must have an up to date contract/statement of terms and conditions, which provides information about what services are included in the fees. Care plans must be improved to ensure that they include up to date information on all aspects of the service users health and social care needs. The care plans must be kept tidy and reviewed at regular intervals. Service users and their relatives must be involved with the production of the care plans and the reviews. All service users must have their prescribed medication in stock and medication must be securely stored. Requirements made by the visiting pharmacist must be actioned. The manager must set up a meeting with service users to listen to their views about the teatime meal which some described as too repetitive. The manager must ensure that the very frail service users are offered regular fluids and snacks, daily records must be kept, which detail the amount of food and drink offered to frail service users, a copy of the records must be sent to the local office of the Commission For Social Care Inspection until further notice. Service users must not be left for long periods in the dining room waiting for their breakfast to be served. Some parts of the home still need redecorating and some carpets cleaning. Several service users complained that the new dining tables were not big enough to allow three wheelchair users to sit at the same table. The dirty wheelchairs must be cleaned and all refuse bins must befitted with lids. The Commission For Social Care Inspection must be notified of all incidents as required in Regulation 37 of the Care Homes Regulations 2001.

CARE HOMES FOR OLDER PEOPLE Abbey Grange Nursing Home Cammel Road Firth Park Sheffield South Yorkshire S5 6UU Lead Inspector Janice Griffin Key Unannounced Inspection 24th May 2006 6:50 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Abbey Grange Nursing Home DS0000021762.V295601.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 Grange Nursing Home DS0000021762.V295601.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbey Grange Nursing Home Address Cammel Road Firth Park Sheffield South Yorkshire S5 6UU 0114 256 0046 0114 261 7962 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) None Larongrove Limited Miss Tracey Jane Turner Care Home 88 Category(ies) of Dementia - over 65 years of age (28), Old age, registration, with number not falling within any other category (60) of places Abbey Grange Nursing Home DS0000021762.V295601.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th March 2006 Brief Description of the Service: Abbey Grange is a care home providing personal care and nursing care. Accommodation is provided for 88 service users. The home is owned by Larangrove Limited and is situated in the Firvale area near to the Northern General hospital a short walk away from the main bus route to the town centre. The nearest shopping area is situated at Firvale. The home is a converted property with extensions, accommodation is provided on three floors that are accessed by a lift. The original property has been extended to provide 88 beds for nursing and personal care with 66 single and 11 double bedrooms. The grounds are accessible and well laid out, the garden sitting areas are attractive and well maintained. The previous inspection report was made available to service users and their families, details of this was on the homes notice board. The weekly fees are: £303 for residential care and £463 for nursing. This information was provided on 24th May 2006. The home charges extra for chiropody, toiletries, clothing, telephone, holidays and hairdressing. Abbey Grange Nursing Home DS0000021762.V295601.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place from 6:50 am to 3:00 pm. As part of the inspection process the inspector spoke to ten service users, one relative, five staff and the manager. Most of the service users were seen during the inspection. Some of the service users were unable to contribute to the inspection process so the inspectors spent time observing the direct care offered to those service users. Observations confirmed that service users were extremely comfortable and at ease in the company of the managers and staff. The relative described the service as in the main very good. A number of records were examined which included, the managers preinspection questionnaire, medication records, three service users care plans, three weeks menus and three weeks staff rotas. Records relating to staff recruitment, service users finances, staff training and the homes quality assurance systems were also checked. Several areas of the building were also inspected. The Commission For Social Care Inspection has received one concern about this home since the last inspection. The concern was about care planning and the care staffs training. The inspector checked out the issues at this inspection and it was found that the staff training was good but the care planning system poor Feedback on the inspection was given to the manager before the inspector left the home. What the service does well: The inspector observed that service users were well dressed in clean clothes and had received a good standard of personal care. Service users had visited the home for trial periods. The manager said that service users were only admitted once it had been determined that the home could meet their needs. Service users were encouraged and supported to maintain positive relationships with their families and friends. Staff handovers were taking place on a daily basis these meetings enabled the staff to discuss the current health needs of service users, to ensure that a consistent level of care could be offered. All service users attended a variety of social and leisure activities and these were based very much on the personal preferences of each individual. The home caters well for service users with physical disabilities. Feedback was being sought on a regular basis from relatives and service users. Abbey Grange Nursing Home DS0000021762.V295601.R01.S.doc Version 5.2 Page 6 One relative spoke positively about the staff team and the care that her relative received. She commented that all the staff was “smashing”. The service users finances were well managed. What has improved since the last inspection? What they could do better: Service users must only be admitted to the home on the basis of a full needs assessment. All service users must have an up to date contract/statement of terms and conditions, which provides information about what services are included in the fees. Care plans must be improved to ensure that they include up to date information on all aspects of the service users health and social care needs. The care plans must be kept tidy and reviewed at regular intervals. Service users and their relatives must be involved with the production of the care plans and the reviews. All service users must have their prescribed medication in stock and medication must be securely stored. Requirements made by the visiting pharmacist must be actioned. The manager must set up a meeting with service users to listen to their views about the teatime meal which some described as too repetitive. The manager must ensure that the very frail service users are offered regular fluids and snacks, daily records must be kept, which detail the amount of food and drink offered to frail service users, a copy of the records must be sent to the local office of the Commission For Social Care Inspection until further notice. Service users must not be left for long periods in the dining room waiting for their breakfast to be served. Some parts of the home still need redecorating and some carpets cleaning. Several service users complained that the new dining tables were not big enough to allow three wheelchair users to sit at the same table. The dirty wheelchairs must be cleaned and all refuse bins must be Abbey Grange Nursing Home DS0000021762.V295601.R01.S.doc Version 5.2 Page 7 fitted with lids. The Commission For Social Care Inspection must be notified of all incidents as required in Regulation 37 of the Care Homes Regulations 2001. 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. Abbey Grange Nursing Home DS0000021762.V295601.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 Grange Nursing Home DS0000021762.V295601.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3 and 6. Quality in this outcome area is: poor. This judgement has been made using available written evidence, discussion with ten service users, one relative and a visit to the home. Some service users have moved into the home without having their needs assessed, this does not ensure that their care needs can be met. Service users were able to have informal introductory visits to the home at the time of their admission. The relative confirmed that this helped the service users to get to know everyone at the home, which made them feel less anxious. No service users have been provided with a contract of care issued by the home. This is poor management practice. There was an available copy of the last inspection report on the homes notice board. This gives information to the service users and their families about the quality of the care provided at the home. This home does not provide intermediate care services. Abbey Grange Nursing Home DS0000021762.V295601.R01.S.doc Version 5.2 Page 10 EVIDENCE: Detailed full needs assessments have not been completed by the referring social worker for all service users admitted to the home. The relative spoken to said at the time of her relatives admission she was able to have an informal introductory visits to the home. Records checked confirmed that service users families had been involved in decisions regarding the arrangements. An up to date contract/statement of terms and conditions had not been provided to service users. Abbey Grange Nursing Home DS0000021762.V295601.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10. Quality in this outcome area is: poor. This judgement has been made using available written evidence, discussion with service users, and observations made by the inspector at the visit to the home. Discussions with service users, and observations made by the inspector confirmed that the staff promoted the service users privacy and dignity. The information in the care plans was not adequate to ensure that the service users health and social care needs could be met. This does not protect the well being of service users. There was no evidence to show that service users and their relatives were involved in the care planning and reviewing process. This does not allow the service users and relatives to have a say in how the service users needs are being met. Some medication practices could cause a risk to the service users health and welfare. Abbey Grange Nursing Home DS0000021762.V295601.R01.S.doc Version 5.2 Page 12 EVIDENCE: All the service users spoken to said that the staff promoted their privacy and dignity .The inspector observed staff knocking on bedroom doors and waited to be invited in before entering. Service user meetings had been held on a regular basis and minutes of these meetings were available within the home. Three service users care plans were checked they were very untidy and information was difficult to retrieve. The care plans did not detail the service users religious and cultural needs and the gender of staff that they wished to assist them with their personal care. Service users and relative were not involved with the production of the care plans or the reviews. Ranges of aids to assist service users with mobility problems were provided; these included lifting hoists and straps, assisted baths, walking frames and wheelchairs. Service users who were able could retain control of their own medication, a lockable facility was not provided in all rooms to store such items. Records were kept of medication received, and disposed of. Medication was noted to be insecurely stored. A prescription was noted to be in a service users case file, the prescription had been given by the service users GP two months previously it appeared that the staff had not sent the prescription to the pharmacist for dispensing. A pharmacist had checked the home’s medication systems in February 2006 and several issues of concern were reported. Abbey Grange Nursing Home DS0000021762.V295601.R01.S.doc Version 5.2 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 the following standard(s): 12,13,14 and 15. Quality in this outcome area is: adequate. This judgement has been made using available written evidence, discussions with ten service users, one relative, five staff and a visit to the home. Service users had access to a range of leisure activities based on their individual choices and preferences. Service users confirmed that the routines of daily living were flexible and suited their individual preferences. Service users were supported with maintaining and developing contact with their family and friends, and they also said that visitors were always welcome at the home. Which creates a home that people want to visit. Two service users said a good choice of food was not offered at teatime and that there were too much sausage and chicken on the menu. Several service users said on most occasions they had to wait for long periods for their breakfast to be served. This does not promote the rights of service users. The records of one service user showed that she was not being given enough fluids on a daily basis. This could have a serious impact on the health and wellbeing of the service user. Abbey Grange Nursing Home DS0000021762.V295601.R01.S.doc Version 5.2 Page 14 EVIDENCE: All the service users spoken to confirmed that staff were extremely supportive and always encouraged them to become integrated into the local community, when they felt able to do this and with the appropriate staff support provided. They also said that the staff supported them with discovering how to enjoy social situations and activities. And generally this was based on the personal preferences of each individual. A programme of the daily leisure activities was displayed on the notice board. Service users confirmed that they had regular contact with representatives from the local churches and that they were able to visit them at the home if they wished. One service user, who was very frail, was on daily fluid balance monitoring chart, the inspector checked the amount of fluid given to the service user over a twenty-four hour period. The records stated that only 300mills of fluid had been offered to the service user over the twenty-four hour period, no records were kept of the food offered to this service user. The inspector observed breakfast and lunch, the meals served looked appetising. Several service users said that at breakfast time, the staff were extremely busy assisting service users to get up and they were not able to serve breakfast until late. The inspector observed some service users waiting over one hour in the dining room for breakfast. Staff spoken to said that the staffing levels deployed in the mornings were not adequate to meet the needs of service users. Eight service users were receiving special diets. Special cutlery and crockery was provided for those service users who had difficulty using knives and forks. Abbey Grange Nursing Home DS0000021762.V295601.R01.S.doc Version 5.2 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 the following standard(s): 16 and18. Quality in this outcome area is: good. This judgement has been made after discussion with ten service users, one relative, five staff members and using available written evidence including a visit to the home. The homes complaints procedure was clear, accessible and contained the necessary information. This is good management practice. Service users were protected from abuse by the awareness of staff through training and the homes procedures. EVIDENCE: The complaints procedure was available for service users, their relatives and staff. The manager confirmed that this would be available in alternative formats and languages should this be requested. All service users, a relative and staff spoken to said that they knew that they could complain if they were not happy about anything and that they felt able to discuss any issues or concerns that they may have with the manager. The complaints record confirmed that no complaints have been made at the home since the last inspection. One concern had been brought to the attention of the Commission For Social Care Inspection by a visiting social worker. The concern was about staffs moving and handling training and care plans. Abbey Grange Nursing Home DS0000021762.V295601.R01.S.doc Version 5.2 Page 16 The inspectors checked the issues of concern out at this inspection and some of the concerns were found to be partially upheld. Staff had received formal adult protection training this included physical, emotional and sexual abuse. The manager was aware of the Sheffield City Councils adult abuse procedures. No allegations of abuse have been made about this home since the last inspection. Staff had been made aware of the action to take in dealing with third party information. Abbey Grange Nursing Home DS0000021762.V295601.R01.S.doc Version 5.2 Page 17 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 the following standard(s): 19 and 26. Quality in this outcome area is: good. This judgement has been made after discussion with ten service users, one relative, five staff members and using available written evidence including a visit to the home. The environment within the home was clean providing a comfortable environment for service users. Some decoration was damaged and one carpet stained making the home look shabby in parts. Three service users complained about the design of the dining tables, which they said, were not suitable for wheelchair users. This design of furniture good impose on the safety and wellbeing of service users in wheelchairs. One refuse bin was not fitted with a lid and some wheelchairs were dirty. This is not hygienic. EVIDENCE: Some parts of the home have been redecorated and the carpets and furniture replaced, but some areas still had damaged decoration and a carpet was noted Abbey Grange Nursing Home DS0000021762.V295601.R01.S.doc Version 5.2 Page 18 to be stained. The bedroom doors were fitted with suitable door locks but lockable facilities were not provided in all bedrooms. Service users could smoke in a designated smoking area. Service users complained that the new dining tables were too small to allow three service users in wheel chairs to sit up to them. They said that they were kicking each other’s feet under the tables. Appropriate seating had been provided in the garden for those service users wishing to sit outdoors whenever the weather permitted. Each floor had a number of toilets and bathrooms. Assisted baths and showers were provided for those service users with mobility problems. Toilets were easily accessible as they were close to lounge and dining areas. All the toilets had been adapted for service users with physical disabilities. Staff confirmed that they were provided with protective clothing if they needed it and that all the equipment was in good working order and that it had been serviced as required. One refuse bin, which contained used gloves and dressings, was not fitted with a lid. Some wheelchairs were noted to be dirty food debris was noted on the wheels. Abbey Grange Nursing Home DS0000021762.V295601.R01.S.doc Version 5.2 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29, and 30. Quality in this outcome area is: good. This judgement has been made after discussion with ten service users, five staff members and using available written evidence including a visit to the home. Care staff had a range of skills and experience, which effectively supported the service users. This will ultimately benefit the health and welfare of the service users. The deployment of staff at breakfast time was not adequate, as the current system does not allow the staff to meet the service users needs. The recruitment information obtained for new staff was adequate to protect the welfare of service users who lived at the home. At least 94 of staff have undertook NVQ training at level 2 or 3, and all staff had completed a range of training relevant to their role. This shows the providers commitment to staff development. EVIDENCE: The staff and service users said that there was always enough staff on duty. However the deployment of the staff at breakfast time needs to be reviewed. Service users had to wait over one hour for their breakfast in one dining room. Three staff files were checked; criminal record checks had been done for all three staff. Two references had been obtained and no gaps were noted in staff’s employment history. Abbey Grange Nursing Home DS0000021762.V295601.R01.S.doc Version 5.2 Page 20 Staff spoken to had an understanding of the home’s fire procedures; they had received training on moving and handling, fire, food safety and infection control. Staff files checked and discussions with five staff and the manager confirmed that all staff had completed detailed induction training. Staff were observed to be approachable and sensitive to the needs of service users and were able to communicate effectively with each person. Staff had completed training on NVQ in care and this had ensured that more than 94 of the staff team were qualified to level 2/3. Staff were being formally supervised at the frequency specified in the Regulations and Standards to fully ensure individual staff development and the monitoring of care practices Abbey Grange Nursing Home DS0000021762.V295601.R01.S.doc Version 5.2 Page 21 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38. Quality in this outcome area is: good. This judgement has been made after discussion with the manager, ten service users, five staff and using available written evidence including a visit to the home. All the service users spoken to and all the staff said the manager was approachable and very professional. This demonstrates a good example to staff. Service user surveys are completed annually. This ensures that the home is run in the best interest of service users. Records were in the main up to date and well ordered to ensure the best interests of service users. The homes policies and procedures met the required standards. Some notifiable incidents were not being reported to the Commission For Social Care Inspection. This is a breach of the Care Homes Regulations. Abbey Grange Nursing Home DS0000021762.V295601.R01.S.doc Version 5.2 Page 22 EVIDENCE: The manager had a job description that clearly defined her roles and responsibilities and staff were aware of her role. She said she was committed to ensuring that the home provides a high standards of care, she has started to complete regular internal audits on all aspects of the service provided by the home. There was a quality assurance system, which sought the views of relatives. The responsible individual visits the home on a regular basis a report is written following the visits. One incident, which could have affected the well-being of a service user, had not been reported to the Commission For Social Care Inspection. No fire exits were blocked and hazardous substances were securely stored. The administrator handles money on behalf of some service users, account sheets were kept, receipts were available for all transactions and all transactions were witnessed by a second individual. Abbey Grange Nursing Home DS0000021762.V295601.R01.S.doc Version 5.2 Page 23 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 2 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Abbey Grange Nursing Home DS0000021762.V295601.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP2 Regulation 5 Requirement All service users must have a contract of care. The contract must detail what is included in the fees, including any extra charges, and the services and facilities provided by the home. All service users must only be admitted to the home on the basis of a full needs assessment, which is completed prior to their admission. The care plans must be tidy so information can easily be retrieved. The service users and their relatives must be involved in the production of the care plans and the reviews. Evidence of their involvement must be in the care plans. Care plans must clearly show that information has been updated. The service users religious, social and cultural needs must be included in their care plans. Details of the service users preference of the gender of the staff assisting with personal care Abbey Grange Nursing Home DS0000021762.V295601.R01.S.doc Version 5.2 Page 25 Timescale for action 01/09/06 2. OP3 14 01/08/06 3. OP7 OP8 15 01/09/06 4. OP7 15 5. OP9 13 tasks must be included in the care plan. All risk assessments on falls must be revised to include how risk can be reduced and what action staff will take to reduce the risk. This has been outstanding since September 2005. Medication must be kept in secure place at all times. When a GP has prescribed medication, it should be obtained immediately. The manager must investigate why a prescription given two months ago, has not been obtained for one service user. The local office of the Commission For Social Care Inspection must be sent a copy of the manager’s findings. Requirements made by the pharmacist must be actioned. The very frail, sick service users must be offered regular drinks and snacks. Records must be kept of all drinks and snacks offered to those service users. A copy of the fluid/food balance monitoring charts used for the frail service users must be sent to the local office of the Commission For Social Care Inspection on a weekly basis until further notice. The service users must not have to wait in the dining room for over one hour until their breakfast is served. The manager and cook must meet with the service users to review the choice of food offered DS0000021762.V295601.R01.S.doc 01/08/06 24/05/06 6. OP15 12 07/06/06 7. OP15 23 01/08/06 8. OP15 23 01/08/06 Abbey Grange Nursing Home Version 5.2 Page 26 9. 10. OP19 OP19 23 23 11. OP19 12 12. 13. 14. 15. OP26 OP26 OP27 OP33 23 23 18 37 at teatime. A lockable facility must be provided in every bedroom. The damaged decoration must be repaired and the stained carpet cleaned or replaced. This as been outstanding since September 2005. The manager must complete a risk assessment on the suitability of the new dining tables for service users in wheelchairs All refuse bins must be fitted with lids. The dirty wheelchairs must be cleaned. The deployment of staff at breakfast time must be reviewed. The local office of the Commission For Social Care Inspection must be notified of all incidents as detailed in Regulation 37of the Care Homes Regulations. 01/09/06 01/09/06 01/08/06 01/07/06 24/05/06 01/08/06 24/05/06 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 Grange Nursing Home DS0000021762.V295601.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 Grange Nursing Home DS0000021762.V295601.R01.S.doc Version 5.2 Page 28 - 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. 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