Inspection on 26/10/06 for Abbey Grange Nursing & Residential Care Home

This inspection was carried out on 26th October 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.

Other inspections for this house

Abbey Grange Nursing &... 14/08/08

Abbey Grange Nursing &... 14/08/07

Abbey Grange Nursing &... 31/01/06

Abbey Grange Nursing &... 07/06/05

Abbey Grange Nursing &... 08/03/05

Abbey Grange Nursing &... 20/04/04

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

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

CARE HOMES FOR OLDER PEOPLE Abbey Grange Nursing & Residential Care Home 61 South Road Weston Super Mare North Somerset BS23 2LT Lead Inspector Barbara Ludlow Unannounced Inspection 10:50 26 October 2006 th 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 & Residential Care Home DS0000020225.V302128.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 & Residential Care Home DS0000020225.V302128.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbey Grange Nursing & Residential Care Home Address 61 South Road Weston Super Mare North Somerset BS23 2LT 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) 01934 623223 01934 414024 enquires@manor-court.co.uk Manor Court Care Homes Ltd Mrs Jean Taylor Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40), Physical disability (3) of places Abbey Grange Nursing & Residential Care Home DS0000020225.V302128.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. 7. 8. May accommodate up to 38 persons aged 65 years and over, requiring nursing care. May accommodate up to 7 persons aged 65 years and over, requiring personal care. Staffing Notice dated 21/12/2000 applies Manager must be RN on Parts 1 or 12 of the NMC Register May accommodate up to 2 persons in the Cedar Lodge Annex who are aged 18-64 years and have a Mental Disorder. May accommodate up to 3 persons between 18 - 64 years of age with physical disabilities, requiring nursing care. May accommodate one person aged 50 years and over. One named Service User, aged 44 on admission; this condition will cease when named service user leaves the home. Date of last inspection Brief Description of the Service: Manor Court Care Homes Ltd owns Abbey Grange. Mr Jan Mohammed is the responsible individual for the company. Mrs Taylor is the registered manager of the home. Abbey Grange offers a total of 40 places. The main home provides predominantly nursing care for older people, although up to 8 service users who require personal care only may be accommodated. Cedar Lodge is a small self-contained unit, which provides personal care for 2 people, aged between 18 and 64 years, who have a mental disorder. In addition, the home offers day care to older people. The day care unit is housed within the main home, but has designated facilities and a separate staff team. Abbey Grange is a converted and extended older property on the hillside of Weston Super Mare. Many rooms enjoy panoramic views over the town, and there is an attractive garden to the front of the building. A passenger lift provides easy access to all areas of the home. Accommodation is provided in 27 single, and 6 double rooms. 8 of these have en suite facilities. The company is in the process of upgrading the accommodation. The communal areas of the home have been refurbished and redecorated to a high standard. The current fees range from £480.00 to £525.00 per week. Abbey Grange Nursing & Residential Care Home DS0000020225.V302128.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key standards inspection was undertaken by B Ludlow for CSCI. Pre inspection information had been completed by the homes Registered manager Mrs J Taylor and was promptly sent to CSCI. Service user feedback and professional visitor information was gathered. Two visits were made to the home to gather sufficient evidence about the service offered and the service users perspective of the care and service received by them. Mrs J Taylor and her deputy were seen on day one. A tour of the main premises was made on day one, to view the environment. The inspector was shown the day centre, which can take up to 10 service users, and she was introduced to staff and attending service users. Service users in residence were seen going about their daily lives at Abbey Grange. There were 30 service users in residence and one person living in The Cedars. One person was too ill to be disturbed, other service users were spoken with during the day and lunch was observed. Staff on duty were seen during day one, a small number of care nursing and ancillary staff were spoken with about their work and training experiences. Records available were sampled; these included care plans and maintenance checks. Recruitment records and contracts were not available on day one. On day two the inspector met with the registered manager and the homes administrator. Copies of documents had been prepared. A tour of The Cedars bungalow and the main kitchen was made. Staff personnel files were sampled and the recruitment process was discussed. A letter of immediate requirement (within 28days) was issued after this visit and prior to the publication of this report. This requirement was made to ensure that all future recruitment practice was of a sufficiently high standard. Feedback was given to the manager on the conclusion on each of the days. Service users and all staff were welcoming and helpful. The inspector would like to thank all who participated in the inspection process for their input. What the service does well: The service has an excellent, informative and current range of information available for prospective service users and their families / carers. Abbey Grange Nursing & Residential Care Home DS0000020225.V302128.R01.S.doc Version 5.2 Page 6 Mrs Jean Taylor is an experienced manager and who has an open and helpful approach to her management role. The care home was in good order, clean, comfortable and homely. The staff were kind and helpful to all service users with polite interactions being observed. Service users spoken with were very positive about living at Abbey Grange. An art and craft activity was seen in progress, participating service users were enjoying this event, which was well supported by staff. The inspector observed a good example of the level of care and support given to service users attending health care appointments outside the home. The escorting staff member on returning gave clear feedback to the manager. The service user commented that they were ‘well cared for at Abbey Grange’. What has improved since the last inspection? What they could do better: Recruitment was poor at this inspection. A requirement was issued at the last inspection and had been acted upon. However the system in place at this inspection was not robust enough to protect service users from the risk of harm, through having detection measures that could prevent an unsuitable person being recruited. An immediate requirement was made to address the deficits found. CSCI received an action plan promptly by return, to explain how the practice and procedures will improve. Oxygen cylinders x 6 were identified that were inappropriately stored on day one. These cylinders were to be returned and were moved for collection. They remained unsecured on day two. This potentially hazardous practice must be avoided. All oxygen cylinders must be held safely and be secured to reduce the risk of injury if one (or more) toppled over. There is also a risk that if a cylinder toppled over the valve could be damaged and it may start to leak. The home had taken advice about oxygen cylinder storage immediately after the inspection and this information and safety signage was seen on day two. Care plans were discussed with the homes deputy, although satisfactory there was some relevant daily life information that had not been captured such as the effectiveness of pain control. More evidence of service user input would also enhance the quality of the care plans. Chemical spray used in the sluice must be labelled so that the content is identifiable, in case of accidental exposure or ingestion. Hazard marked Abbey Grange Nursing & Residential Care Home DS0000020225.V302128.R01.S.doc Version 5.2 Page 7 chemicals must be stored in line with Control of Substances Hazardous to Health (COSHH). 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 & Residential Care Home DS0000020225.V302128.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 & Residential Care Home DS0000020225.V302128.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): 1,2,3,4,5 The outcome for this area was good. The home has an informative statement of purpose and a helpful service user guide. The contract is clear and describes all extra charges. A trial period is not stated in the contract or the homes other literature. Pre admission assessment is made to help determine whether or not care needs can be met at the home. EVIDENCE: The home has a brochure for anyone enquiring for placement at the home. The statement of purpose and service user guide has been revised and these were sampled and found to be informative and helpful. The service user guide was devised by the Manager and is a small booklet with blank pages for ‘notes’. The statement of purpose invites visits to the home to help prospective service users with their final decision making. A copy of the homes contract was seen, this does not state that there is a trial period. Abbey Grange Nursing & Residential Care Home DS0000020225.V302128.R01.S.doc Version 5.2 Page 10 The home currently has an interim care bed, which is funded by social services. This arrangement allows those who are improving in hospital but that are not fit enough to return home, to be discharged into short term care at Abbey Grange. The service user feedback received by CSCI in July from 6 of the 8 respondents indicated that not enough information about the home was received prior to the making a decision to come here. Two persons describing themselves as coming to the home from hospital responded that they had not received information about the home. One also stated that it was their decision to stay here. The new brochure with pictures should be helpful with this. All 8 respondents indicated their satisfaction with the care and support given to them at the home. Emergency admissions are avoided where possible, the home aims to complete the information procedure within 48 hours and the admissions procedure within 5 days. One person who had been admitted in an emergency had a full care plan; they also explained their satisfaction with the care they had received since arriving at Abbey Grange. The manager explained that admissions are usually taken during the afternoon to allow dedicated staff time to the new resident to help them to settle and to label clothing etc. Prospective service users are invited to join current residents for a meal. A trial period is not stated in the homes contract or other literature. Abbey Grange Nursing & Residential Care Home DS0000020225.V302128.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): 7,8,9,10 The outcome for this area was good. All service users had a care plan, these were regularly reviewed. Service users benefit from regular professional community health care input. The medications were well managed. (Oxygen cylinders for returning, their storage was poorly managed See NMS 38.) Observations indicated good staff/ service user interactions that were respectful and kindly. EVIDENCE: Care plans were sampled and positive feedback was received from the GP that visits the home once per fortnight. There is a key worker identified for each of the service users, each key worker being responsible to 6 –8 service users. This was not discussed with these staff at this inspection. Seven care plans were sampled for persons with a range of care needs. There was health care input for the monitoring of chronic health conditions such as diabetes. Observations are made and recorded regularly. Dependency is also monitored regularly. Monthly reviews are made and recorded. Abbey Grange Nursing & Residential Care Home DS0000020225.V302128.R01.S.doc Version 5.2 Page 12 The homes care plan style was clear but there was room for documentation of the outcomes and ongoing review in the daily recording, for example, pain control intervention. This was discussed and examples were given to the deputy manager at the time of the visit. One care plan was seen where a routine catheter change had been slightly delayed, there was no recorded explanation for this. Wound care management was documented with risk assessment and reviews made. The home has good relationships with the PCT and community nursing staff; wound care advice is taken up via them if required. One service user was seen that was very pleased to be at Abbey Grange and felt they had made a significant health gain with the care provided here. Medication management was examined. Amounts of medication received are recorded separately to the Medication Administration Record (MAR). Some but not all hand transcribed medication had two signatures. The home has photo Identification of service users with the MAR charts and a list of staff signatures. The fridge temperature was recorded and was seen to be within the required temperature range. Allergies were indicated on the service users charts. 7 oxygen cylinders were seen on the first floor landing, 6 were free standing and insecure. The Manager arranged for the return of these cylinders and gathered information from the British Oxygen Company (BOC). These cylinders had been moved to the ground floor on day two but remained free standing and therefore not securely stored, there is a risk of injury if the heavy cylinders topple over, valves could be damaged which could allow oxygen to leak out. The care of frail service users was seen to be carefully and regularly attended. Evidence of pain control management was seen in the sampled care plans. A booklet has been prepared for relatives in the event of a service users death. This booklet has been written and designed by the manager; it contained useful information and contact numbers. Abbey Grange Nursing & Residential Care Home DS0000020225.V302128.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): 12,13,14,15 The outcome for this area was good. Service users are able to choose whether or not to join the activities offered. Community activities are available and attended. The home has its own minibus transport. Meals are social occasions, tables are nicely laid and the food is well presented. EVIDENCE: Service user activities were seen. Painting and card making were in progress; there was a good level of staff supervision and assistance as required. The activities are held in the area of the communal lounge that overlooks Weston Bay; it has good natural light and is a very pleasant room. Staff and service users spoke of the community day centres they attend with the support of staff from the home. The home has good community links to access tea dances, a drama group and an art and sewing class, which held locally at a ‘drop in’ centre. One service user reported ‘having made friends at the home’ with other residents and the staff. Abbey Grange Nursing & Residential Care Home DS0000020225.V302128.R01.S.doc Version 5.2 Page 14 The activities coordinator confirmed that one to one input is given and is available to those who are less well. Events at the home are advertised on the lounge notice board, a ‘Harvest Supper’ with the new Lady Mayoress was planned for the day after the inspection. Families and friends were invited to attend. Other information included on the board was the menu, a sundries price list, the homes newsletter and a number of thank you cards. The hairdresser visits the home on Wednesdays. Service users who were joining in with the activities confirmed that they were enjoying themselves. Feedback from other service users indicated that some choose not to join in but are happy spending their time as they choose. One service user responded that the activities at the home were not suitable for them, another responded saying they wanted more activities. The home asks in its service user guide that service users who buy or bring in their own televisions will need to buy a licence or claim age exemption from the cost if applicable. However if service users have a TV that belongs to the home there is no cost. The manager is currently planning to use the home funds raised at the Fete and by raffles, to renew the homes own service user TV sets. The manager stated that she is also planning to establish a residents committee. Lunch was observed, fifteen service users were able to eat together at the tables in groups of up to four, some service users remained in their armchairs at lunchtime. Those who received assistance were helped one to one in a discreet manner. Lunch was conducted in a relaxed way, as a social occasion. Abbey Grange Nursing & Residential Care Home DS0000020225.V302128.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): 16.18 The outcome for this area was assessed as adequate. All staff seen observed kind and helpful in their interactions with service users. Service users confirmed that they were well cared for. Recruitment practice was unsafe. EVIDENCE: The home has policies and procedures in place to protect service users from harm. These included the ‘No Secrets in North Somerset’ guidance for the protection of vulnerable adults. Recruitment files were inspected, there was evidence of good practice and also of less careful practice. A robust procedure is planned for all future staff recruitment practice. See NMS 29. The feedback from service users included that the service user ‘would go to Jean’ the Registered Manager if they needed to complain. The home administrator had advised the inspector that a swipe card system was being introduced and the card would only be issued on completion of the full recruitment procedure which included the receipt of all the required documentation, in line with Care Home Regulation 19, Schedule 2. The manager explained that two complaints had been received at the home concerning lost false teeth; these complaints were dealt with at the time. Abbey Grange Nursing & Residential Care Home DS0000020225.V302128.R01.S.doc Version 5.2 Page 16 These complaints had not been logged but appropriate action was described as taken. A recommendation is made for the improvement of recording practice. Abbey Grange Nursing & Residential Care Home DS0000020225.V302128.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): 19,20,21,22,23,24,25,26 The outcome for this area was good. Service users were happy with their accommodation, which was nicely decorated and well presented. Individual accommodation can be personalised and looked comfortable. EVIDENCE: The home has a quiet restful ambience. The communal areas are clean and well organised. Service users were seen during the day making use of the communal lounges and the dining room, which was seen to be nicely laid for lunch and tea. Many were spoken with and others observed as they spent their time in these communal areas. The rapport observed between staff and service users was relaxed, friendly and respectful. Activities today were held in the dining room, which lends itself well for art and craft work, with tables that take 4 persons for meals accommodating two for artwork. This room has views across the bay of Weston Super Mare. The homes accommodation is on five levels, Ground to the fourth floor. All floors are accessible by passenger lift and wide staircases. Abbey Grange Nursing & Residential Care Home DS0000020225.V302128.R01.S.doc Version 5.2 Page 18 The homes service user guide contains information indicates the floor layout and bedroom sizes. Many of the double rooms are occupied as single rooms. Furniture and seating looked comfortable and aids were used where indicated. Bedrooms were individually personalised and made homely. The home has assisted bathing and toilet facilities. There is one shower facility that is not used, as the floor gradient is steep and the space confined. One commode was seen in use that had rusted badly, this was changed. One bed rail was identified that required slight attention to adjust the distance between the top of the bed and start of the rail; this was brought to the managers attention during the tour of the premises. All other rails in use appeared to be well fitting and had protective bumpers available. Abbey Grange Nursing & Residential Care Home DS0000020225.V302128.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): 27,28,29,30 The outcome for this area was adequate. The home had sufficient staff on duty at the inspection. There is an established staff team and they have good access to training opportunities. The homes recruitment procedures were inadequate. EVIDENCE: The home adheres to the staffing notice and exceeds this to meet the needs of service users. Regular measurement of the service users dependency scoring is used to assess the staffing needs of the home. The day unit has a separate staff group. The Cedars has dedicated daytime staffing, night cover is managed by the homes night staff. The staff for these areas were seen during the inspection. Service users commented that ‘staff are lovely’, ‘well looked after’. The home has a registered nurse manager, a deputy nurse manager and registered nurses team to ensure that there is a registered nurse on duty at all times. The pre inspection questionnaire indicated that the home has care staff that are qualified to NVQ Levels 2 and 3 to meet 50 of the workforce. Separate catering and domestic staff are employed. This provides the manager sufficient skill mix of staff to run the home effectively. Abbey Grange Nursing & Residential Care Home DS0000020225.V302128.R01.S.doc Version 5.2 Page 20 There is a learning culture at the home. The home has three student nurses from Derby University and three staff provide mentorship. There is support for the homes staff that is reported to be very good, from the University. There has been some turnover of staff since the last inspection but no agency use was indicated on the pre inspection information presented to CSCI. Recruitment is jointly managed between the manager and the homes administrator. A mix of good and poor recruitment practice was evidenced. CRB checks are accessed through an umbrella body. One CRB check had not been returned and a copy of a ‘portable’ CRB was seen on file. The use of previous CRB disclosure is no longer acceptable. It was also evident that the person concerned had worked in an unsupervised capacity. Mr Janmohamed the company Responsible Individual was looking into this and will take appropriate action to remedy the situation. A robust procedure is planned for all current and future staff recruitment practice. For two staff, references had not been received until after the person had started working at the home. A ‘to whom it may concern’ reference had been accepted. There was no evidence that any supporting telephone references had been attempted. This matter was addressed by the manager in response to the immediate requirements made at this inspection. The home administrator advised the inspector at the inspection that a swipe card system was being introduced and the card would only be issued on completion of the full recruitment procedure, which included the receipt of all the required documentation, in line with Care Home Regulation19, Schedule 2. Abbey Grange Nursing & Residential Care Home DS0000020225.V302128.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): 31,32,33,34,35,36,37,38 The outcome for this area is good. Residents benefit from an experienced Manager and a supportive management team. Safety checks are made, however attention is required to the safe management of chemicals and medical gases. EVIDENCE: The home has an experienced Manager and a supportive management team. There is an open management approach and the staff spoken with confirmed that they feel able to approach the manager for support. New staff receive training and induction. Training in the last 12 months was reported to have included Manual handling, food hygiene, fire training and health and safety. Personnel files sampled had evidence of certificated qualification such as NVQ 3 and training records for mandatory training and infection control. Abbey Grange Nursing & Residential Care Home DS0000020225.V302128.R01.S.doc Version 5.2 Page 22 The home is clean, hygienic and is well maintained. There is evidence of ongoing investment in the home. The home is addressing internal quality auditing and has looked at the quality of the food; no analysis was available. The admission information has been re visited and improved and the manager is currently working on an admission booklet. A booklet for the relatives of a deceased service user has been designed by the manager and was seen to contain a lot of useful information and contact numbers. Certificates of registration with CSCI and the homes Employers liability insurance were displayed. The home has a visitor’s book and next to it a sign to invite and encourage visitors to use the available hand cleansing gel before entering the home. This is an infection control precautionary measure. The records seen at this inspection included: The fire alarm was serviced on 16/08/06.The last drill for 9 staff was March 06. Weekly alarm testing is carried out, the last was dated 25/10/06. Emergency lighting is checked on a monthly basis, the last test was dated 25/10/06. Fire extinguishers had been serviced and were in date. The hoists and the passenger lift were serviced in September 06. The homes boilers had been serviced May 06.Other checks and maintenance information was reported on the pre inspection questionnaire. The management of chemicals in the sluice and oxygen cylinders could have been safer. 6 oxygen cylinders for return to BOC were seen to be freestanding and therefore an unnecessary hazard to health and safety. One unlabelled chemical spray and a COSHH hazard marked chemical were seen in the sluice room, attention must be paid to store and label chemicals in line with COSHH guidance. Accident records were seen, these were fully recorded. Abbey Grange Nursing & Residential Care Home DS0000020225.V302128.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 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 3 3 3 3 3 3 3 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 3 3 3 3 3 1 3 2 Abbey Grange Nursing & Residential Care Home DS0000020225.V302128.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 OP29 Regulation 19.-(1) Sched. 2 Requirement Two written references and a CRB disclosure or PoVA First check must be in place before staff start work in the home. This is outstanding from the last inspection, 31/01/06 2 OP29 18(2) The registered person shall ensure that persons working at the care home are appropriately supervised. Action: You must provide and record regular staff supervision. Staff must be supervised until a full CRB disclosure is obtained. Immediate requirement issued. 3 OP29 18(3) 18 (3) (a) Where the care home provides nursing to service users; the registered person shall ensure that at all times a suitably qualified registered nurse is working at the care home. DS0000020225.V302128.R01.S.doc Timescale for action 16/11/06 16/11/06 16/11/06 Abbey Grange Nursing & Residential Care Home Version 5.2 Page 25 Action: Registered Nurse PIN numbers must be checked to confirm that an appropriate and active entry is registered with the Nursing and Midwifery Council. Immediate requirement issued A person is not fit to work at a care home unless- (d) full and satisfactory information is available in relation to him in respect of the following matters – (i) each of the matters specified in paragraphs 1 to 6 of Schedule 2; Action: Two satisfactory written references relating to the person must be obtained before appointing them to work at the home. CRB checks with a POVA First must be taken up and a minimum of a satisfactory POVA First must be received before the person is employed to work at the home. Workplace supervision must be in place for any person commencing work on the home’s receipt of a satisfactory POVA First check, until a full and satisfactory CRB check is returned to the home. 5 OP9 13(2) The registered person shall make arrangements for the safe handling, safekeeping, safe administration and disposal of medicines received into the care home. Oxygen cylinders must be stored DS0000020225.V302128.R01.S.doc 4 OP29 OP18 19(1)(5) (d)(i) 16/11/06 30/11/06 Abbey Grange Nursing & Residential Care Home Version 5.2 Page 26 6 OP36 18(2) 7 OP38 13(4)(a) securely and safely. The registered person shall 18/12/06 ensure that persons working at the home are appropriately supervised. Staff must receive supervision in line with employment procedures. The registered person shall 30/11/06 ensure that- all parts of the home to which service users have access are so far as is reasonably practicable free from hazards to their safety; Chemicals must be labelled and stored in line with COSHH guidance. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP36 OP16 Good Practice Recommendations Care staff should receive formal recorded supervision. Complaints should be fully logged Abbey Grange Nursing & Residential Care Home DS0000020225.V302128.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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