Inspection on 11/07/06 for Abbey Hey Care Home Ltd

This inspection was carried out on 11th July 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Abbey Hey Care Home Ltd 26/09/07

Abbey Hey Care Home Ltd 22/12/05

Abbey Hey Care Home Ltd 19/04/05

Abbey Hey Care Home Ltd 17/11/04

Abbey Hey Care Home Ltd 25/05/04

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 Hey Care Home Ltd 1 Delemere St Oldham Lancashire OL8 2BY Lead Inspector Michelle Haller Key Inspection 10:00 11 July 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 Hey Care Home Ltd DS0000005484.V294548.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 Hey Care Home Ltd DS0000005484.V294548.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbey Hey Care Home Ltd Address 1 Delemere St Oldham Lancashire OL8 2BY 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) 01616249518 0161 624 9518 Dignity Care Group Carole Ann Kearns Care Home 39 Category(ies) of Dementia (2), Dementia - over 65 years of age registration, with number (25), Old age, not falling within any other of places category (15), Physical disability over 65 years of age (15) Abbey Hey Care Home Ltd DS0000005484.V294548.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 39 service users to include: *up to 15 service users in the category of OP (Old age not falling within any other category). *up 15 service users in the category of PD(E) (Physical disability over 65 years of age). *up to 25 service users in the category of DE(E) (Dementia over 65 years of age). *up to 2 service users in the category of DE (Dementia under 65 years of age). No service user under the age of 55 to be admitted into the home. The service must at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 22nd December 2005 2. 3. Date of last inspection Brief Description of the Service: Abbey Hey is a purpose built residential home for up to 39 service users, situated close to Oldham town centre, public transport and local amenities. The home is registered to provide care for service users in the following categories: Older People, service users with Dementia and those with a Physical Disability. Accommodation is provided in 34 single rooms, of which 33 have en-suites, and three shared rooms with en-suites. On the ground floor there are two large lounges and two smaller rooms, which can be used for dining or socialising, plus a large dining room. There is an additional lounge for service users on the first floor. Bathrooms and toilets are fitted with aids and adaptations in order to promote service users independence. Service users have access to a small-enclosed patio area and a small seating area to the front of the property. Abbey Hey Care Home Ltd DS0000005484.V294548.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was a key inspection for Abbey Hey, which included a site to the home. The inspection covered a period of 10 hours over two days. The method of inspection included looking at the care records of four service users, assessment of policies, procedures and other documents concerning the running of the home, five service users, three visitors, two members of staff and one church minister were also interviewed. The interactions between service users, visitors and staff were also observed, over lunch, during organised activities and in the course of walking about the property. The inspector looked round the building to assess its suitability, cleanliness and comfort for service users. The inspection report is available at the entrance of the home. The fees charged at the time of inspection were in the region of £345.00 each week. What the service does well: The overall impression of the home is that it is a quiet, comfortable home, run in an open manner that suits the needs of the service users currently in its care. The service provides service users and their representatives with opportunity to find about the home prior to moving in. Furthermore the home ensures that they have a good idea of the needs of service users and their ability to meet those needs prior to any move. The manager and staff have a good rapport with relatives and professionals visiting the home. Health provision and the response to health needs is good and the home makes sure that doctors, nurses and other health intervention is provided whenever needed. The manager takes active steps to deal with the needs and reduce the incidence of service user who fall or have accidents. Care plans are monitored and revised to reflect the changing needs of service users. The home provides accessible, comfortable and, for the most part clean, accommodation. The management team are aware of any shortcomings and are willing to put plans in place to remedy problems with the general repair of the home. Abbey Hey Care Home Ltd DS0000005484.V294548.R01.S.doc Version 5.2 Page 6 Activities, when they are provided, are of a good standard, keeping service users entertained and encourage and them to take an interest in the world around them as well as each other. The home has developed a positive relationship with a local church community. Meals and snacks in the home are plentiful and to the liking of most service users. The home deals with complaints fairly and transparently. Staff are aware of how to safeguard service users against abuse. What has improved since the last inspection? 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 Hey Care Home Ltd DS0000005484.V294548.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Abbey Hey Care Home Ltd DS0000005484.V294548.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users and their representatives are informed of the facilities and service in the home and contractual responsibilities of both parties made clear allowing service users to make an informed choice. Service users needs are assessed prior to admission, and so staff are provided with sufficient information to ensure they are able to meet service users needs EVIDENCE: The homes’ previous inspection report was readily available for people to read on request, and the manager stated that a copy of the service user guide was offered to each perspective service user or their representative. Each care file examined contained a completed needs assessment and this provided detailed information about the care and support required by the individual, as well as some information about their interests, likes and dislikes and previous social history. Abbey Hey Care Home Ltd DS0000005484.V294548.R01.S.doc Version 5.2 Page 9 Each file contained a statement of terms and condition however the service user or their relative had not signed these. The manager stated all aspects concerning living in the home was discussed prior to admission. It was also acknowledged, however, that there was insufficient evidence that this action was a part of the admission process. Service users and their relatives who were interviewed and able to give an opinion, confirmed their belief that they had been given enough information about the home before making a decision move in. One person commented that the home had a ‘good reputation locally.’ Abbey Hey Care Home Ltd DS0000005484.V294548.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for 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. The information about service users provided to care staff is sufficient for staff to know, for the most part, what actions they need to take in order to promote the general health of service users. The homes policy and procedures for dealing with the administration and storage of medication is safe and promotes the wellbeing and safety of service users. Care staff for the most part preserve the privacy of service users at all times, however, the dignity and choice of service users is not always upheld. Abbey Hey Care Home Ltd DS0000005484.V294548.R01.S.doc Version 5.2 Page 11 EVIDENCE: All care plans examined had been reviewed on a regular basis and for the most part related to the assessed needs of service users. Care plans were updated in response to major changes in needs such as to prevent the development or promote the healing of pressure areas, or to prevent weight loss. The information in care-plans that had been reviewed indicated that the needs of some service users had changed a great deal. Completing a reassessment of needs for these services users would have made it easier to develop care plans that plan to limit the effects of deterioration as well as in response to deterioration taking place. Some aspects of monitoring in the home could be improved for example, the Heatwave Policy was on display and jugs of fluid were placed around the home. Unfortunately there was no record of the amount of fluid taken by individual services users, or whether they had been encouraged to drink extra, this information is particularly important when treating people with urinary tract infections. In addition, although ultimately the responsibility of the general practitioner and practice nurse, the progress of long term conditions such as diet or medication controlled diabetes were not recorded by home. These issues were discussed with the manager. Staff have not received updated infection control and there were no hand towels in the toilet areas. The manager stated that staff use hand-cleaning fluid, however it was pointed out that this is only effective when used in conjunction with hand washing. It was also noted that the use of aprons and gloves when supporting service users was not consistent. In addition some staff wore jewellery other than simple wedding bands. Reports and other checklists confirmed that service users received regular optician checks, were offered yearly flu injections and had their feet seen to by a podiatrist. Family members stated that they or the home escorted service users to hospital appointments when necessary. Comments from service users included ‘The carers are not bad they do every thing for me.’ And when asked about the staff stated they’re ‘not so bad- they do everything for me’. One relative also commented, ‘ They (the residents) seem okay they get good care.’ And ‘They (the home) keep the family informed’. Abbey Hey Care Home Ltd DS0000005484.V294548.R01.S.doc Version 5.2 Page 12 Daily reports did not fully reflect all the actions taken in respect of service users health however it was clear from other information such as weight charts, tissue viability monitoring and body maps, diary entries, letters and the communication book that, in general, the health provision in the home is of a good standard. It was evident through observations that staff discussed and provided treatment discreetly. It was also noted that staff concerning the manner in which they sometimes approached service users requires additional training and supervision. Staff need to habitually gain the co-operation and consent of service users prior to applying any moving and handling techniques. Discussion with the district nurse and a general practitioner visiting the home indicated that, in general, they had no concerns in respect of the health care provided in the home. Both identified that staff followed specialist care-plans and advice, and the manager reported changes in service users condition. And both indicated that the home maintained a positive and professional relationship on behalf of service users. They also confirmed that the home requested medical assessments and treatment in good time. The medication policy and procedure was examined and drug administration observed. Medication was stored safely and pictures available of service users. The staff administering the medication had received appropriate training and was knowledgeable about the medication being handled and was also aware of the action to be taken in respect of ordering medication or in the event of misadministration. Staff supervision records suggested that the distribution of morning medication could take all morning. The time needed to complete this procedure could be reduced if the home purchased a lockable and portable medication trolley. Such equipment would also reduce the temptation for staff to sign medication ‘as taken’ prior to instead of ‘after’ the medication has been consumed. Abbey Hey Care Home Ltd DS0000005484.V294548.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 outcome in this area is good. This judgement has been made using available evidence including a visit to this service. The home provides service users with a lifestyle that meets their individual needs and promotes their psychological wellbeing and social development through making they are treated as individuals. The home provides a good quality of meals and snacks in a pleasant environment that are enjoyed by service users. EVIDENCE: The home is decorated with a display of pictures of activities and arts and crafts completed by those living in the home. The home employs a trained activities co-ordinator for 20 hours each week that takes the lead in designing and organising a variety of activities to meet the varying needs of service users. A report for each activity is prepared and this includes the expected outcome for each activity, which participated and whether the person enjoyed the activity and what support they required to join in. Abbey Hey Care Home Ltd DS0000005484.V294548.R01.S.doc Version 5.2 Page 14 Activities are varied and includes quiz events, floor dominoes and darts, reading and discussing the newspaper, shopping at the shop situated on the premises. On the first day of inspection service users were observed enjoying floor drafts organised by the co-ordinator. It was noted that the hours included early evening and weekend activities. Day trips and excursions are also organised. Although there was ample evidence that service users were provided with group activities it was noted that there was little opportunity for individual activities to be organised. The home operates a key worker system, however, none of the service users interviewed, who could give an answer, were able to name their key worker, or say in what way they received individual attention. Discussion with staff indicated that at times they were limited in providing activities when the activities co-ordinator was not available, they were aware, however, of the needs and preferences of service users. One service users commented ‘They cater for everything but it’s up to us and how we feel.’ A Christian Act of Worship also takes place in the home on a monthly basis. The Minister involved stated that these services were well attended and enjoyed by a significant number of service users. The Church also host coffee mornings and other social events that would welcome residents from the home if they could be escorted by staff. Relatives, friends and other visitors were observed coming and going throughout the time of the inspection. Comments from visitors included ‘Never any problem visiting, and ‘Everyone is friendly, there is never an unpleasant smell’. Service users also confirmed that visits could take place at a time convenient to them. The homes’ security arrangements includes a gate which is secured by a keypad coded lock, and it was noted that all regular visitors to the home were able to enter the home independently as they had been given this information. Throughout the day ambulant service users and those who could exercise a clear choice, were given the opportunity to access all parts of the home and the local community as they chose. Furthermore people got up and had breakfast at whatever time they liked. Meals provided in the home are varied and to the taste of the service users. On the day of inspection service users were observed enjoying breakfasts that ranged from simple toast to, bacon, eggs and sausages with beans or tomatoes. Abbey Hey Care Home Ltd DS0000005484.V294548.R01.S.doc Version 5.2 Page 15 The lunchtime choice was ham, vegetable casserole and green beans. Everyone enjoyed this. Observations made at lunchtime suggested that some service users may benefit from an occupational health assessment so that adapted spoons, knives and forks could be considered as though able to eat independently, one person grew weary of eating when the food continually fell from their forks, spoons and plate. A record of drinks and meals taken by service users should also be maintained. Service user comment about food included ‘Can’t grumble- sometimes get two dinners – but mostly sandwiches at teatime. For breakfast we can choose I have cereals or eggs.’ Examination of the menus indicated that meals were varied and culturally appropriate traditional British foods, and included meat casseroles, pies, liver and onions, fresh fish and vegetables included runner beans, sweet corn, cabbage and cauliflower. The cook has completed National Vocational Qualification 2 (NVQ) in catering, and is also participating the Better Food Better Business initiative run by the local Environmental Health department. Abbey Hey Care Home Ltd DS0000005484.V294548.R01.S.doc Version 5.2 Page 16 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 17 Quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. The arrangements in place for complaints and adult protection are satisfactory, the service users and their representatives are aware of how to make a complaint, and feel confident thy would be listened to. Staff are knowledgeable about basic adult protection issues, thus showing service users are suitably protected. EVIDENCE: The home’s complaints policies and procedure is clearly written. Though not fully understood by all who were interviewed it was clear that everyone was confident that, if they spoke to the manager about any concern they would be listened to and dealt with quickly and fairly. Certificates confirmed that a number of staff have completed the adult protection training provided by the local authority. Staff who were interviewed described the types of actions and omissions that could be considered to be abuse. Not all staff that were interviewed had completed the training. The home is in the process of redesigning the training calendar and is considering whether to supplement the local authority training with additional in-house training using a training package. Abbey Hey Care Home Ltd DS0000005484.V294548.R01.S.doc Version 5.2 Page 17 Observation demonstrated that for the most part staff spoke to service users in a courteous manner. It was noted however, that on occasion staff commenced working with service users without making conversation or eye contact until part way through the task. One investigation under Protection of Vulnerable Adults guidelines (POVA) has been carried out in the home since the last inspection and the outcome was that the complaint was unsubstantiated. It must be noted, however, that although this incident was notifiable under Care Home Regulations 2001 the home failed, through oversight, to inform the Commission for Social Care Inspection about the inquiry. Abbey Hey Care Home Ltd DS0000005484.V294548.R01.S.doc Version 5.2 Page 18 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 majority of the areas in the home were clean and comfortable, providing service users with a homely and safe environment in which to live. EVIDENCE: A tour of all the communal and the majority of the private accommodation was undertaken. Service users were observed accessing all parts of the home, including a pleasant garden area independently using frames, walking sticks and wheelchairs. Areas that may have posed a risk such as stairs down to the basement and doors into the kitchen were made inaccessible through the use of coded keypads. High seats were in use over toilets and handrails were also strategically placed throughout the home. Abbey Hey Care Home Ltd DS0000005484.V294548.R01.S.doc Version 5.2 Page 19 The majority of the home was free from bad odours and discussion concerning the general appearance of some parts of the home took place. The manager and directors acknowledge that additional refurbishment and cleaning in some areas is needed. Service users bedrooms were examined and found to be comfortably furnished and homely. Many contained the furniture, ornaments and pictures that belonged to the occupant. Those who were interviewed stated that for the most part they were satisfied with their rooms. One person felt that she would like to have more than one easy chair so that visitors did not have to sit on her bed. This comment was passed on to the manager. Abbey Hey Care Home Ltd DS0000005484.V294548.R01.S.doc Version 5.2 Page 20 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 using available evidence including a visit to this service. The home provides adequate numbers of staff that have received training to enable them to carry out their tasks safely and knowledgably. Staff are vetted before they start work at the home ensuring they are suitable for work with older people. EVIDENCE: On the first day on inspection there were 34 people living in the home and staff the compliment was the manager; six care staff; one hobby therapist; one cook and one member of staff cleaning and dealing with the laundry. The duty roster indicated that for the most part there were five members of staff plus the manager on duty each morning with a cross over period in the afternoon. A senior care staff and a first-aider were on duty at each shift. And an oncall roster was clearly displayed so extra support could be called for at night. The roster indicated that at times are staff were expected to complete domestic chores and this meant that they were not available for service users. Abbey Hey Care Home Ltd DS0000005484.V294548.R01.S.doc Version 5.2 Page 21 This issue was discussed with the manager and one of the directors. They stated that at times this was unavoidable due to sickness and it was easier to bring in extra care staff. They acknowledged that during the morning staff availability was reduced. When questioned however, service users and their representatives felt that staff were readily available stating that call bells were answered quickly. ‘You only have to press the buzzer and they are here.’ Staff records confirmed that the recruitment and selection process in the home is safe and sound. Each file contained a copy of the application form, confirmation of Criminal Record Bureaux checks, two references and items confirming proof of identification. The home employs 30 members of staff and 14 have NVQ level 2. Other staff are in the process of completing this award. The manager stated that six members of staff have completed basic first aid training. Records and certificates also confirmed that staff have received training in dementia care, medication administration, first aid, fire safety, adult protection, senior staff and the activities co-ordinator had completed the Age Concern course ‘Yesterday, Today and Tomorrow’ and a course about the provision of activities in a residential home, a small number of staff have also received level one training in dementia care. Additional training needs identified during the course of the inspection included specialist dementia care training for all staff; an introduction to diabetes, updated infection control training and moving and handling training. Other topics were also discussed and the manager is currently in discussion with the training providers, including the local authority and district nurse, to identify what training is available for staff. Three care staff were interviewed and each was complimentary about working in the home. All were willing to attend training courses and identified personal training needs that they hoped would be addressed in the coming year. No new members of staff were interviewed however, each person described the induction process they had received. Senior staff described the process of induction that was completed with new starters. This included the new carer shadowing more experience staff, teaching through modelling and showing new staff what to do, observing the work carried, one-to-one training about the needs of service users and talking through care plans, daily reports and other activities concerned with providing direct and completion of an induction workbook. Abbey Hey Care Home Ltd DS0000005484.V294548.R01.S.doc Version 5.2 Page 22 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, 36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The day-to-day management of the home is efficient. Additional work and some changes are needed, however, before the management processes fully promote the safety of service users or provides sufficient monitoring of the work carried out by staff. Quality monitoring is inconsistent and does not give opportunity for all involved to have a say about the quality and development of service in the home. The finances of service users was not inspected on this occasion, this will be fully assessed at the next inspection. Abbey Hey Care Home Ltd DS0000005484.V294548.R01.S.doc Version 5.2 Page 23 EVIDENCE: The manager has achieved the Registered Managers award. Over the period of the inspection the manager presented as a caring and professional individual who was flexible and approachable in her dealings with service users, staff and others who visited the home. Certificates also confirmed that she had attended training courses in order to update her knowledge. Discussion with staff and members of the management team indicated and records confirmed that supervision for staff is sporadic and carried out by senior managers. Supervision also tends to occur at times when there may be issues be addressed, although this is appropriate, it was also noted that some members of staff benefited from frequent access to supervision while others received none. Observation of staff going about their daily work suggested that additional supervision as they carried out their tasks would be beneficial. The quality assurance monitoring system was inspected. The information was dated and the process did not encourage anonymity. Furthermore there was no opportunity for staff, district nurses or others involved in the home to comment on the quality of services provided. The home employs a maintenance worker who arranges for the monitoring and checking of appliances, services and utilities such as gas and electric. On the day of inspection the passenger lift in the home was serviced. The accident records book was examined and entries were clear and correlated when cross-referenced with the daily records of service users. It was pleasing to find out that the manager completes an analysis and risk assessment of accidents, and action is taken to reduce the risk. Referral to the Falls Clinic, changes in the manner in which staff are deployed and changes in foot wear are a few of the actions initiated by the manager in response to the findings of risk analysis. Health and safety matters seem to be in order with the exception of staff requiring training in Infection control and dealing with hazardous substance and some fire safety issues. The fire inspection had highlighted a number of issues and on the date of this CSCI inspection very little action had been taken because the registered individuals had not read the document in full. In addition to this, the magnetic release mechanism on the fire door leading into a small lounge was broken and the door was wedged open with a chair. The manager has commenced weekly checks of fire safety equipment as evidenced in the fire safety logbook. No other action, however, had been taken. Abbey Hey Care Home Ltd DS0000005484.V294548.R01.S.doc Version 5.2 Page 24 This issue is of major concern and is the main reason for the home being considered poor in this area. These concerns were discussed with the manager. Abbey Hey Care Home Ltd DS0000005484.V294548.R01.S.doc Version 5.2 Page 25 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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 1 x x 2 x 1 Abbey Hey Care Home Ltd DS0000005484.V294548.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation Schedule 4 (13) Requirement Timescale for action 01/10/06 2 OP33 3 OP36 4 OP38 5 OP18 The registered person must be able to demonstrate that service users are provided with the supervision necessary to remain consume enough fluids. 24 The registered person must ensure that a comprehensive quality monitoring system is established in the home. 18(2) The registered person must ensure that all staff are supervised in accordance to their responsibilities and developmental needs. 18 ( c ) (i) The registered person must ensure that staff receive training in the aspects of health and safety relevant to their role. 37 The registered person must fulfil their responsibility to inform CSCI of the need to inform CSCI about incidences and investigation in the home. 01/11/06 01/10/06 01/10/06 01/09/06 Abbey Hey Care Home Ltd DS0000005484.V294548.R01.S.doc Version 5.2 Page 27 6 OP3 14 7 OP38 23 (4) The registered person should 01/10/06 make sure that staff understand and recognise that the needs of service users can change to such an extent that a total reassessment of needs is required with the development of a totally new care plan. The registered person must 01/09/06 ensure that issues concerning fire safety is adhered to strictly 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. OP15 Refer to Standard Good Practice Recommendations The registered person should make sure that service user who may have difficulties feeding themselves are assessed and appropriate equipment provided. Abbey Hey Care Home Ltd DS0000005484.V294548.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Ashton-under-Lyne Area Office 2nd Floor, Heritage Wharf Portland Place Ashton-u-Lyne Lancs OL7 0QD 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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