Inspection on 19/06/06 for Abbey Grove

This inspection was carried out on 19th June 2006.

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

The inspector 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 Grove 18/07/07

Abbey Grove 05/02/06

Abbey Grove 12/11/05

Abbey Grove 30/11/04

Abbey Grove 15/07/04

Abbey Grove 24/02/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Abbey Grove 2-4 Abbey Grove Eccles Gtr Manchester M30 9QN Lead Inspector Sue Jennings Unannounced Inspection 19th June 2006 10:00 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 Grove DS0000008331.V301759.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 Grove DS0000008331.V301759.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbey Grove Address 2-4 Abbey Grove Eccles Gtr Manchester M30 9QN 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) 0161 789 0425 Coveleaf Ltd Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Abbey Grove DS0000008331.V301759.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5 February 2006 Brief Description of the Service: Abbey Grove is a care home providing accommodation for 19 older people who require personal care only. The registered provider is Coveleaf Ltd. Abbey Grove is a detached property situated in a residential area of Eccles. The home is set in small, enclosed grounds, which provide parking facilities to the side, rear and front of the property, and a patio area leading to a formal lawn area to the side of the building. A ramp provides access to the patio area. Accommodation for residents is provided on the ground and first floor. A passenger lift provides access to all floors. The home offers accommodation in 13 single bedrooms and three double rooms. There is ample communal space comprising of two lounge areas, quiet sitting areas and a designated smoking area. The dining room is situated next to the kitchen. Abbey Grove DS0000008331.V301759.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit was undertaken as part of a key inspection, which includes an analysis of any information received by the Commission for Social Care Inspection in relation to this home prior to the site visit. The inspection was an unannounced inspection19 June 2006. During the course of the inspection time was spent talking to the registered manager, residents and several members of staff to find out their views of the home. Time was spent examining records, documents, residents and staff files. A tour of the building was also conducted. The majority of requirements from the previous inspection had been addressed and there was evidence that this home was working towards developing the service and meeting the National Minimum Standards. The current fees for accommodation at the home are £395.00 per week depending on a financial assessment. All meals, laundry, NHS chiropody and in-house entertainment is inclusive in the fees. Additional costs include hairdressing, dry cleaning, trips out and telephone calls. As this inspection only looked at a limited number of standards this report should be read together with the previous and any future reports to gain a full picture of how the service is meeting the needs of the residents living there. What the service does well: The décor, furniture and the facilities available at the home are of a good standard. There are two lounges and a dining area on the ground floor. The atmosphere in the home was warm and welcoming. The standard of cleanliness throughout the home was good one resident said ”It is always very clean”. Several residents who lived at the home and two relatives described positive experiences of the way staff related to them and spoke of how friendly the staff were. One resident stated “staff are very good and they treat you with respect”. Further comments received by residents included “ I like it here and the staff are nice”, and “I am very well looked after”. Abbey Grove DS0000008331.V301759.R01.S.doc Version 5.2 Page 6 Staff were observed to be pleasant and courteous with residents, were seen to have good interactions with residents and were observed assisting with residents individual needs. Staff treated residents with respect and dignity. Staff were seen to knock on doors before going into a room. The staff spoken to said that residents are able to go to bed and get up when they choose. The residents spoken to confirmed this. There was a menu board in the dining room for listing the meal for the day. On the day of the site visit the board had not been completed because the marker pen had ‘dried up’, however all the residents spoken to said that the cook had asked them that morning what they would like for lunch. Meals served appeared to be nutritious, well balanced and nicely presented. The cook asks residents on a daily basis what they would like to eat from the menu choice for that day. Alternative meals are available on request. Comments from residents were very positive and included things like “the food is really nice”, “there is always a good choice of food” and “they come and ask you every day what you want”. On the day of the site visit one of the residents was celebrating their birthday and the cook had baked a birthday cake for the residents to have with the evening meal. During the site visit a bouquet of flowers arrived for the resident and staff were seen to sit and chat with the resident. What has improved since the last inspection? Residents who spoke to the inspector said that they were very happy living in the home and that they were kept “well informed” about what is going on. The home is working towards reviewing all care plans, which include risk assessments. Medicines requiring cold storage were now being stored in a small portable fridge although this type of fridge was not suitable for purpose. Following a pre-admission assessment the home now writes to the prospective resident to confirm that the home is/is not suitable to meet their care needs. A number of bedrooms and communal areas had been redecorated since the last inspection. New carpets and soft furnishings had been fitted. This is part of an ongoing programme of refurbishment. A number of training events had been planned including Adult Protection, Dementia training, Care Planning and a number of staff had been nominated for NVQ level 2 training, which starts in September 2006. Abbey Grove DS0000008331.V301759.R01.S.doc Version 5.2 Page 7 What they could do better: 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 Grove DS0000008331.V301759.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 Grove DS0000008331.V301759.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): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are admitted to the home after a full assessment of needs has been undertaken. This ensures that residents care needs can be met. EVIDENCE: A pre-assessment form is in use to ensure prospective residents are only admitted on the basis of a full assessment. The assessment included the involvement of the prospective resident, his/her representatives and any relevant professionals. The manager and/or the deputy manager of the home undertook the pre-admission assessment. The assessment of need provided useful information of the events leading up to the resident’s admission into the home. Care manager assessments of needs were in place and the home had conducted thorough in-house assessments of need. Falls risk assessments had been undertaken where necessary. Abbey Grove DS0000008331.V301759.R01.S.doc Version 5.2 Page 10 On admission to the home, residents have a further assessment period during which time the home formulates its own care plan. One resident spoken to said that they were aware of what a care plan was and that they had seen their own. This home does not provide intermediate care facilities. Abbey Grove DS0000008331.V301759.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 adequate. This judgement has been made using available evidence including a visit to this service. Overall the health and personal care needs of the residents were being met at the home, however the management of medication did not fully safeguard the residents. EVIDENCE: A random sample of care plans was examined. Each resident had an individual plan of care, which had been generated from a Care Manager’s needs assessment and the homes own assessment process. Care plans included risk assessments although some work was required to ensure that risks and the action required to reduce risks are clearly identified. There was evidence to show that residents had been involved with the formulation of their individual care plans and in the review process. One resident spoken to said that they knew what the care plan was and had seen their care plan. Abbey Grove DS0000008331.V301759.R01.S.doc Version 5.2 Page 12 It was clear that the home was working hard to improve the care plans. The care plans included information on individual care needs and identified the actions required to meet resident’s needs. Discussions with the deputy manager provided evidence of ongoing commitment to training and reenforcing the principles of good care practice. All residents were registered with a local General Practitioner (GP). The GP visited the home on request residents could see the GP in the privacy of their own room. During the last announced inspection there was a number of shortfalls identified in the safe handling and administration of medication in the home and a total of three requirements were made relating to this standard. Since the inspection the manager had addressed almost all the requirements and made good progress in providing a safe medication system. Medication was stored in a metal trolley. This was not secured to the wall at the time of the site visit but there was evidence to show that arrangements had been made for this to be done within the week, as the supplier of the medication system had been waiting for the spare key to be delivered. The controlled drug register and the MAR sheets were signed following the administration of a controlled medication. The home did not have a list of staff members authorised to give medication with a record of their approved signatures and initials. It is recommended that this is maintained and that dates that staff received medication administration training be added to this list. All medication administration sheets contained a photograph of residents. Staff must not administer medication until they have received appropriate training. One resident said “the staff help me with my tablets. I usually get them at the same times”. It was evident that the staff on duty had a good understanding of good practice issues associated with privacy and dignity. During the inspection staff were observed knocking on bedroom doors and waiting for a response. All residents spoken to said that they were treated with respect by the staff and said that staff made sure their dignity was maintained when delivering personal care. Abbey Grove DS0000008331.V301759.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 evidence including a visit to this service. The home provided a good environment for the residents who live there with some activities available. Residents were supported to maintain contact with family and friends, and in general were able to exercise choice over their life. Meals served at the home were nutritious, well balanced and offered a healthy and varied diet for residents. EVIDENCE: Evidence of activities, including a collage of Christmas parties in the form of photographs was seen during the inspection. There was also some evidence of artwork completed by residents in the home. The home did not employ an activity organiser and it was the responsibility of the staff in general and students on placement at the home to undertake activities such as board games, cards, quizzes and film afternoons. Residents said that their friends and relatives were made to feel welcome by the staff and confirmed that they could see their visitors in the privacy of their own rooms. Abbey Grove DS0000008331.V301759.R01.S.doc Version 5.2 Page 14 One relative told the inspector that she was made to feel welcome and felt comfortable in visiting the home at any time of the day. Visitors were observed to come and go during the course of the site visit. The families of most residents were involved in assisting with financial management. In general the residents were offered choice, however, one resident said “ I am told when I can have a bath, I don’t want to have a bath at that time and I think I should be able to choose, I know the girls are busy because some of the people here need a lot of help, but I don’t need a lot of help just with a bath really and I prefer to have a shower anyway”. Residents wishes must be included in care plans and steps taken to comply with these wishes. Where this is not possible the reasons why should be recorded. The menus offered a varied, wholesome and nutritious diet. A choice of alternative meals was available. The cook consulted residents on a daily basis for their preferred choice of meal from the menu. On the day of the site visit the daily menu board had not been completed, however residents spoken to said that they were aware of what meal they were having because “the cook comes to us every day to see what we want for dinner”. Residents spoken to gave positive feedback about the quality of the meals in the home. One resident said “they will always do you something different if you don’t fancy what is on the menu” and “they are very good the food is lovely” All the residents are registered with a local General Practitioner (GP) and where possible residents have retained their own GP. Residents can either attend religious services in the community or a minister of their chosen faith can visit them in the home if preferred. Family and friends are encouraged to visit regularly. Where this is not possible staff at the home will assist residents to maintain contact via telephone or letter. The home has a complaint procedure and information about how to make a complaint is included in the home’s statement of purpose and function.. Abbey Grove DS0000008331.V301759.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 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Policies and procedures in place protected residents from abuse but staff had not all received training in what to do in the event of an allegation of abuse, which could affect the safety and well being of the residents. EVIDENCE: The home had a complaint procedure that was available to residents. Residents spoken to were aware of how to make a complaint and one resident said “I have no complaints, if I had something to say I would tell the manager” another resident said “there is nothing to complain about here”. The home had policies and procedures relating to abuse/protection of vulnerable adults, a copy of the Manchester Multi-Agency policy for the Protection of Vulnerable Adults from Abuse and a ‘Whistle Blowing’ policy. Since the last key inspection an allegation of verbal abuse had been received and had been referred to the local Adult Protection unit using Salford’s Local Adult Protection Procedures. This incident was not reported directly to the Commission for Social Care Inspection by the home. The provider must ensure that all notifiable incidents are reported in line with regulation 37 of the Care Homes Regulations 2001. The incident had been Abbey Grove DS0000008331.V301759.R01.S.doc Version 5.2 Page 16 investigated and the outcome reported to the Commission for Social Care Inspection. A random site visit was made to the home on the 12th April 2006 following the results of the police investigation and a requirement was made that all staff receive updated training relating to Adult Protection issues. During this site visit it was reported that although all staff had been nominated to attend Adult Protection training only one actually attended. The provider must ensure that all staff received Adult Protection training. Two members of staff were spoken to during this site visit and were not fully aware of the actions to be taken if there was an allegation of abuse, butr both said they would immediately report the incident to the line manager. It was recommended that a flow chart of the action to be taken in the event of an allegation be produced and displayed in a prominent position for the senior care staff when they are in charge of the home. No other complaints had been received by the home or by the Commission for Social Care Inspection. Abbey Grove DS0000008331.V301759.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 using available evidence including a visit to this service. The premises are safe and the home’s environment including the standard of hygiene was well maintained both internally and externally. EVIDENCE: The home felt comfortable and homely. All areas of the home were tastefully decorated and furniture was of a domestic nature and of a good standard. The home had a programme of routine maintenance and renewal of the fabric and decoration and a number of bedrooms and communal areas had been redecorated since the last inspection. Health and Safety, environmental health and fire safety checks and inspections had been carried out as required. The home provided a passenger lift to enable residents to access the first floor. Abbey Grove DS0000008331.V301759.R01.S.doc Version 5.2 Page 18 A variety of electrical hoists were available, however the bath hoist in the first floor bathroom was not charged and therefore did not work. Appropriate aids were fitted i.e. assisted baths and raised toilet seats for residents who required assistance doorways into the communal areas allowed wheelchair access. There were privacy locks fitted to bathroom and toilet doors and an emergency call system was available in bedrooms and all communal areas. The need for any other aids would form part of the assessment carried out prior to admission. A sample of residents’ bedrooms was seen and found to be comfortable and personalised. One resident said “I have a nice room. I brought in my photographs and some ornaments”. Residents’ bedrooms had been fitted with a privacy lock suited to their capabilities and accessible to staff in emergencies. Residents were provided with a key on request unless a risk assessment suggested otherwise. Abbey Grove DS0000008331.V301759.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The number of staff within the home was sufficient to meet the needs of the residents and in general had the relevant skills and training to be competent in their job role. Improvements were needed in recruitment procedures to fully protect residents and in the recording of training provided. EVIDENCE: The staffing rota showed that enough staff had been deployed throughout the week to meet the needs of the residents living in the home. The staff rota included the staff names and hours worked. The standard of cleanliness in the home indicated that sufficient domestic staff were employed. The files of four staff employed in the home were checked. All documentation relating to employment was found to be on file. However, one employee had a Criminal Record Bureau check on file that had been brought from a previous employer. The address on the CRB disclosure was different from the actual address of the member of staff. In order to fully protect residents the home must ensure they check the proof of address documents thoroughly when applying for CRB/POVA checks. This was discussed with the deputy manager who immediately contacted the member of staff and advised them that they needed to obtain a new CRB disclosure. The staff files examined contained an induction format but these had not been Abbey Grove DS0000008331.V301759.R01.S.doc Version 5.2 Page 20 completed. All staff must undergo induction training and this must be evidenced. Two members of the care staff were spoken to both had a good understanding of the needs of older people. Staff spoken to confirmed that they had attended induction training and some study days. One staff member said that he had not received any training in the safe administration of medication even though they were responsible for administering medication. All staff with the responsibility of administering medication must receive accredited training. One member of staff confirmed that they had an annual appraisal and had recently attended dementia care training. Staff gave positive comments about the support offered by the manager. Both members of staff spoken to said that they are awaiting NVQ training one at level II and one at level III. Abbey Grove DS0000008331.V301759.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 adequate. This judgement has been made using available evidence including a visit to this service. The home has systems and procedures in place, which safeguard and protect residents’ financial interests and promote the health, safety and welfare of the residents and staff. EVIDENCE: The home manager was not on duty at the time of the site visit. The deputy manger reported that the home does not handle/manage residents finances. Families assist residents who are unable to manage their own finances. All residents were in receipt of their personal allowances and all DSS payments are paid directly into individual bank accounts of residents. Abbey Grove DS0000008331.V301759.R01.S.doc Version 5.2 Page 22 It is recommended that residents’ meetings are held as a way of getting residents’ views on the services and to contribute to the development of the home. The home’s certificates of registration and public liability insurance were displayed in the entrance hall. These were accurate and up to date. Fire equipment had been regularly maintained and staff had received fire awareness training. A health and safety policy was in place and risk assessments of the premises and safe working practices had been carried out. This was to ensure that both residents and staff had relevant information to enable them to live and work in relative safety. Relevant certificates were on file to show that appropriate servicing of equipment used by residents in the home had been carried out. Residents were introduced to the inspector and invited to give them their views about the home. Residents spoken to said that the manager and staff were approachable. One resident said that the staff were always there if you needed them. There was evidence that fire drills took place and that staff were aware of what to do in the event of a fire. There was no fly screen fitted to the kitchen window and the window was open. A requirement is made that a risk assessment is carried out in regard to whether a fly screen is required. Abbey Grove DS0000008331.V301759.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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 3 X X 2 Abbey Grove DS0000008331.V301759.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 OP7 Regulation 15 Requirement Risk assessments must clearly identify the risk and the action required to reduce the risk. The registered person must ensure that a suitable refrigerator with a lockable facility be used for storing medicines requiring cold storage and records maintained of temperature. Staff responsible for the administration of medication must receive accredited training. 3. OP14 15 The registered person must make every attempt to respect residents choice in respect of meeting care needs. All staff must undergo induction training and evidence of this must be held on file. The registered person must ensure that all staff attend updated training relating to adult protection procedures. (Timescale 01/05/06 not met). DS0000008331.V301759.R01.S.doc Timescale for action 01/08/06 2. OP9 13 01/08/06 01/08/06 4. 5. OP30 OP18 18 13 01/08/06 01/09/06 Abbey Grove Version 5.2 Page 25 6. OP29 18 7 Schedule 2 The registered person must ensure that robust recruitment procedures are in place and strictly followed, including checking the proof of address information provided for CRB/POVA checks. The registered person must submit an application for the registration of the manager to CSCI. The registered person must ensure that all manual handling equipment is charged and in working order, and that a risk assessment is carried out with regard to whether a fly screen is needed at the kitchen window. 20/07/06 7. OP31 8 20/07/06 8. OP38 13 01/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP9 OP29 Good Practice Recommendations It is strongly recommended that the dates on which staff received training in the administration of medication be kept with a list of staff names, initials and signatures. It is strongly recommended that the home introduce a change of address form which should be held on individual staff files to ensure they have the current address details of all staff employed in the home. The registered person should recommence residents’ meetings and offer residents opportunities to collectively and individually voice their views on the service provision and contribute to the development of the home. 4. OP33 Abbey Grove DS0000008331.V301759.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ 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 Grove DS0000008331.V301759.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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!