Inspection on 26/09/07 for Abbey Hey Care Home Ltd

This inspection was carried out on 26th September 2007.

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 Hey Care Home Ltd 11/07/06

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 Mrs Fiona Bryan Unannounced Inspection 26th September 2007 09:30 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.V347990.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.V347990.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 Abbey Hey Care Home Limited 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.V347990.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. 11th July 2006 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. Fees for accommodation and care at the home range from £343 to £380 per week. Additional charges are also made for hairdressing, newspapers and chiropody. Abbey Hey Care Home Ltd DS0000005484.V347990.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection, which included a site visit, took place on Wednesday, 26th September 2007. The home was not told beforehand of the inspection visit. All key inspection standards were assessed at the site visit and information was taken from various sources, which included information known about the service, observing care practices and talking with people who live at the home, visitors to the home, the manager and other members of the staff team. Three people were looked at in detail, looking at their experience of the home from their admission to the present day. A partial tour of the building was conducted and a selection of staff and care records was examined, including medication records, employment and training records and staff duty rotas. Since the last key inspection a random inspection to assess the progress of steps that have been taken to comply with the requirements made at the previous inspection was undertaken on 16th March 2007. The home had made progress in a number of areas but further action was still required to ensure the requirements were fully met. A short report of this inspection was given to the home and is available on request for any member of the public wishing to read it. Before the site visit, residents and relatives’ surveys were sent to the home to distribute, but none had been received back at the time of writing this report. Since the last inspection a new manager has been appointed at the home and we sent her a form to complete before the site visit to tell us what she thought they did well and what they need to improve on. We feel she demonstrated a reasonable awareness of the home’s shortfalls and felt she was enthusiastic and keen to make improvements. What the service does well: The home is comfortable, homely and clean and residents, who appeared relaxed and content, were well supervised by staff, who always seemed to be nearby, offering people drinks and generally ensuring that they had what they needed. Abbey Hey Care Home Ltd DS0000005484.V347990.R01.S.doc Version 5.2 Page 6 An activities organiser is employed and a range of social activities are provided, including sing-alongs, quizzes, board and card games, arts and crafts and trips out. Most people spoken to said they liked the food provided by the home and the menus included a wide range of mainly classic English dishes that were appropriate for the group of residents living at the home. Visitors said that they were made welcome and that the residents they came to see generally presented as being well cared for and happy. Staffing levels were satisfactory and over 50 of the care staff had achieved an NVQ in care. Recruitment procedures ensured that people were vetted properly before working at the home; this meant that residents were protected from abuse. What has improved since the last inspection? What they could do better: Information collected during the assessments of residents needs to be fully up to date and available to staff so they can make sure that all the care needs for that person are identified and planned for. Abbey Hey Care Home Ltd DS0000005484.V347990.R01.S.doc Version 5.2 Page 7 Staff need to work on making sure that care plans are as detailed as possible so everyone knows what the resident can do for themselves, what they need to do for the resident and how the resident should be monitored to make sure that their needs are met. Staff need to follow procedures for the recording of controlled medicines more robustly, to ensure that an accurate record is kept of the numbers of medicines in the home. The manager must make sure that records relating to health and safety, such as fire drill records, are properly maintained and available. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Abbey Hey Care Home Ltd DS0000005484.V347990.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 Hey Care Home Ltd DS0000005484.V347990.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 is not applicable. Quality in this outcome area is adequate. All residents are assessed before coming into the home, although systems need to be improved to ensure that all relevant information is easily accessible to staff. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: Three residents were case tracked and the care files of several other residents were examined in relation to specific care needs identified by us. Initial admission details were included in all care files but these were not always dated so it was unclear how up to date the information was and, consequently, how relevant it was. Abbey Hey Care Home Ltd DS0000005484.V347990.R01.S.doc Version 5.2 Page 10 Assessments had been obtained from social services, which were generally quite detailed. Some of the information was not always transferred on to the admission records that the home used and that were more commonly read by the carers. This meant that, in one case, it was not possible from the home’s admission forms to understand the reason why the resident had needed admission to the home, even though the social services’ assessment on further reading made it clear what the reasons were. Additionally, some of the care needs outlined by social services had not been addressed in the person’s care plans. The manager said that she had started visiting any prospective resident either at home or in hospital prior to their admission. Visits such as this had not been previously undertaken and are good practice, as the manager can ensure that all relevant information about the person’s care is known before admission and also allows the prospective resident to meet someone from the home and ask any questions that they wish to. During the site visit one person was admitted as an emergency. The manager took details about the person’s care needs by telephone and it was noted that on the resident’s arrival, staff were very welcoming and reassuring, helping the resident to settle in and making them feel comfortable. Staff said that when new residents were admitted, the manager gave them information about their care needs before they came into the home. Abbey Hey Care Home Ltd DS0000005484.V347990.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. Records are not always kept in sufficient detail to enable staff to deliver and monitor care effectively. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: Three residents were case tracked and the care files for several others were looked at regarding specific issues identified during the inspection. Care plans were generally person-centred but could be more detailed, with more information about what the resident could do themselves and what specific care staff need to provide. Abbey Hey Care Home Ltd DS0000005484.V347990.R01.S.doc Version 5.2 Page 12 One person who had been admitted for respite care had very limited care plans in place, although they had been at the home for several weeks. The manager said this was because they had kept expecting that the resident would leave but their stay had carried on longer than originally thought. This person did have several care needs that required care planning to ensure that staff were clear about the care they needed to provide and how they were to monitor the resident’s condition. Risk assessments were generally in place for moving and handling, nutrition and falls and assessments had also been put in place for risks that were specific to individual residents. However, the risk assessments did not always contain enough information about how staff could minimise and monitor the risk to residents and there was not always an appropriate corresponding care plan. It appeared from the daily records that staff were not always carrying out the instructions in residents’ risk assessments; daily records showed that one resident was being moved hourly when their risk assessment stated that they should be helped to move their position every two hours. The manager was advised to review with the carers exactly what was happening as moving the resident hourly during the night would have a major impact on the resident’s ability to sleep. The weight of each resident had been recorded in each file until August 2007 but no-one appeared to have been weighed for over a month. Further discussion with the manager found that people’s weights had been recorded in a separate book and had not always been transferred to each resident’s own file. Records should be kept in individuals’ own files so that all relevant information is readily available when staff review the care plans. Staff were recording the fluid intake of a number of residents on daily charts. These were, however, not completed accurately. It was recommended to the manager that intake charts were only commenced where a clear need for this was identified in people’s care plans and staff were diligent in completing them accurately. Care plans and risk assessments were usually reviewed monthly and had been discussed with the resident or their representative. Residents had seen GP’s, opticians, dentists and podiatrists. nurses came into the home regularly to see some residents. The district In all the files viewed, there were a number of days when no entry had been made by staff about the resident’s condition or progress. A statement should be written each day to maintain a record of the care provided to the resident and to help in monitoring their condition. Abbey Hey Care Home Ltd DS0000005484.V347990.R01.S.doc Version 5.2 Page 13 A visitor said that when they visited they always found their relative clean and well cared for, and that staff were aware of her relative’s needs and treated her with respect and kindness. Residents during the site visit were generally well presented. One resident was unkempt and the reasons for this were outlined in their care plan; however the management plan to direct staff in how to deal with this could have been more detailed. Staff used a handover book, which was kept in the reception area, to record when residents had had baths, etc. The location of this book was discussed with the manager, as residents’ confidentiality was potentially breached. Examination of several medication records showed that regular medicines had, in the main, been received, administered and recorded satisfactorily. However, there were two discrepancies in the controlled medicines records, one being an error in counting many days previously, that had not been identified, despite the drug having been administered daily. The second error related to a staff member failing to sign that a medicine had been administered the night before. The manager said she would ensure that both errors were rectified. Abbey Hey Care Home Ltd DS0000005484.V347990.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. Staff are aware of the need to provide opportunities for social stimulation and interaction for people living at the home and, in the main, meet these needs well. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: Since the last inspection a new activities organiser has been appointed who works 25 hours per week. The home is decorated with a display of pictures of activities and arts and crafts completed by those living in the home. In the reception area a “residents’ shop” is provided. The shop is decorated with old adverts, posters and memorabilia, which made it interesting for residents to browse. Items such as toothpaste, shaving foam, sweets and socks were available to buy. Magazines were kept in a magazine rack in reception for residents to take and read as they wished. Abbey Hey Care Home Ltd DS0000005484.V347990.R01.S.doc Version 5.2 Page 15 Details were displayed around the home about forthcoming events and activities, such as a trip to the local fish and chip restaurant. A record was available detailing the different pursuits residents had been involved in. These ranged from reminiscence, board games, noughts and crosses, gardening, sing alongs, quizzes and cards to dominoes, relaxation exercises, life stories, arts and crafts and bowling. Residents had recently been on a trip to Blackpool. The record showed which residents had participated and gave a good overview of whether they had enjoyed the activity. The manager said she was trying to develop the key worker system and the activities organiser was spending time explaining this to the residents. Expansion of the key worker system and further development of the care plans for people’s social care needs may help staff to identify specific interests that could be pursued with individuals who are not able to or do not wish to join in with group activities. During the site visit most some by choice stayed in around the home freely encouraged to visit at any residents were seen sitting in the lounges, although their own rooms. Residents were observed moving and visitors said they were made welcome and time. A set menu operates over a four-week period. Examination of the menus showed that a nutritious and varied diet was provided by the home. Residents had a choice of cereals, porridge, prunes, grapefruit and cooked options for breakfast. Typical food for the main meal of the day included roast dinners, casseroles, meat and potato pie, poached and baked fish, shepherd’s pie, and lamb, turkey and pork steaks. Lighter teas included food such as fish fingers, jacket potatoes, poached egg or beans on toast, bubble and squeak, liver and bacon hot pot, quiches and flans. Meals for the day were displayed on a whiteboard outside the two dining rooms. Lunch on the day of the site visit was lamb hotpot or sandwiches followed by chocolate sponge and custard or ice cream. Tea was hot dogs, chips and salad or egg on toast followed by peaches and cream. A large dining room accommodated most of the residents whilst a smaller dining room had seating for about six people. Both rooms were clean and tidy, with the tables attractively set. The larger lounge had easy listening music playing and several of the residents were humming or singing along whilst they waited to be served. The atmosphere was very pleasant and calm, with carers going around asking residents if they wanted extra bread and butter with their hotpot and offering both hot and cold drinks. Abbey Hey Care Home Ltd DS0000005484.V347990.R01.S.doc Version 5.2 Page 16 The lamb hotpot did not look especially appetising, as it was not accompanied by any vegetables and consequently looked somewhat bland. One resident said she did not like the look of it and the carer asked her to try it and if she did not like it she would get her a different meal. The resident said that it tasted better than it looked and did eat it all. Most of the residents asked said that their meal was nice; one resident said it was “so-so”. One resident said the food was “like my mother used to give me”. Care staff were attentive and noticed when one resident was not eating her meal – a carer went to help her cut the food up more but then sat down and started to feed her as it was clear she would not be able to eat it without help. Since the last inspection, plate guards and adapted cutlery have been obtained to help some residents maintain their ability to feed themselves. Throughout the day staff were seen offering residents hot and cold drinks on a very regular basis. Abbey Hey Care Home Ltd DS0000005484.V347990.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. People living at the home confirmed they had confidence in raising concerns and felt their views were listened to. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: The complaints policy was available in the reception area of the home. Staff were aware of the procedure to follow if they received a complaint from a resident or visitor. A relative said that if she had any complaints, she would feel confident that the manager would deal with it appropriately; minor concerns that she had raised in the past had been addressed to her satisfaction. A record of complaints was available. One complaint was received by the CSCI since the last inspection and was forwarded to the provider to investigate under the home’s complaints procedure. The manager investigated it to the best of her ability, as she had not been in employment at the home when the incident took place. Abbey Hey Care Home Ltd DS0000005484.V347990.R01.S.doc Version 5.2 Page 18 A group of staff were spoken to and asked what the procedures were if they suspected abuse. All the staff were able to describe the procedures they would follow and were aware that they could report matters to an outside agency if they were unhappy with how any issue was dealt with internally. Most staff said they had attended training in safeguarding adults, although certificates to evidence this were not available, as the manager was in the process of updating the staff records. Two safeguarding incidents were reported to the CSCI and the way they were dealt with by the manager was looked at during the random inspection in March 2007. Since the incidents, the home has kept the CSCI better informed about occurrences in the home. Records, however, are not in a format that that manner that maintain the confidentiality of individuals. Furthermore, information is not always fully transferred into the individual records of those involved. Abbey Hey Care Home Ltd DS0000005484.V347990.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. The standard of the environment within the home is good, providing people with an attractive and homely place to live in. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: A tour of the home was conducted. The home was clean and tidy, whilst people’s individual rooms were homely and personalised with ornaments, furniture and mementos. All the bedrooms except one provided en-suite facilities. Abbey Hey Care Home Ltd DS0000005484.V347990.R01.S.doc Version 5.2 Page 20 Since the last inspection investments have been made in new furniture for the lounge and dining areas, new carpets and redecoration. The manager said that, since her appointment, she had asked for help from Social Services to assess what specialist equipment was needed and had acted on their advice by ordering additional equipment, such as mobile commodes, feeding cups and adapted cutlery. A pleasant patio area leading from one of the lounges did need some weeding and maintenance; the manager said it was planned to paint the fence and provide planters to make the area more attractive for residents to sit outside. During the inspection work was in progress painting the reception area and hallways. A small room was designated for residents wishing to smoke. The manager had plans to refurbish the lounge on the first floor and utilise it as a quiet lounge for residents wishing to read or listen to music. At the present time, this room is not really used. The manager said she was also arranging to install overhead tracking in one bathroom, as the space was limited and presented difficulties for staff assisting residents with mobility problems. Abbey Hey Care Home Ltd DS0000005484.V347990.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. The home provides adequate numbers of staff that have received training to enable them to carry out their tasks safely and competently. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: On the day of the site visit a staff meeting had been arranged in the afternoon. Following the meeting, we spoke with a group of staff who said that there were generally enough staff on duty to enable them to meet the needs of the residents; if there were shortages, staff said that the manager usually booked agency staff to cover shifts. Examination of the staff duty rotas showed that staffing levels were, in the main, satisfactory. Two staff personnel files were examined. Each file contained a copy of the application form, confirmation of Criminal Record Bureau checks, two references and items confirming proof of identification. It was recommended that references are checked for authentication. Abbey Hey Care Home Ltd DS0000005484.V347990.R01.S.doc Version 5.2 Page 22 A new staff member said that she had received induction training from the manager. This person was an experienced carer and had undertaken health and safety training in her previous job; however, she had been told that she would have to attend all mandatory training again as part of her induction and this was being arranged. The manager said induction training was arranged through Oldham MBC and was in line with Skills for Care specifications. Of 22 care staff, 12 had successfully obtained NVQ level 2 and a further seven had enrolled for the training. This equates to 54 of care staff being trained at the present time. Staff said that they had received a lot of training over the past few months and the manager said that training had been sourced through Oldham MBC and other external agencies. Training that had taken place included safeguarding adults and dealing with challenging behaviour, infection control, health and safety and food hygiene. Staff rotas showed days when staff had been allocate to attend training. The manager said she was in the process of updating the staff training files to include certificates of attendance and was aware that the records needed improving. Abbey Hey Care Home Ltd DS0000005484.V347990.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37 and 38 Quality in this outcome area is adequate. The manager has a good understanding of the areas in which the home needs to improve and now needs to develop a clear plan and vision for the home and a robust system to implement and monitor the changes required. This judgement has been made using available evidence, including a visit to this service. Abbey Hey Care Home Ltd DS0000005484.V347990.R01.S.doc Version 5.2 Page 24 EVIDENCE: Since the last inspection a new manager has been appointed who has commenced the process for registering with the CSCI. The new manager has achieved the registered manager’s award, NVQ level 4 and is an NVQ assessor and moving and handling facilitator. The manager said that one of her main priorities since her appointment had been to read the reports from the last key inspection and the random inspection in March 2007, to see what shortfalls had been identified in the service and to start to address them. The manager demonstrated a good understanding of the issues raised and was able to describe some of the steps she had taken to make improvements. The manager said that there had not yet been any residents or relatives meetings but she was planning to hold an open day in the near future. She had started to hold staff meetings; a meeting for senior carers was held two weeks before the site visit and a full staff meeting for all grades of staff was held on the day of the site visit. Staff said that the manager was very approachable and that they also saw the managing director and the regional manager regularly. The managing director and the regional manager were at the home on the day of the site visit and attended the staff meeting. It was noted that they knew the residents well, calling them by name and mentioning their preferred routines, such as where they liked to sit; this showed that they did spend time at the home and with the residents forming an opinion about how the home was running. Although the manager initially said that she had not yet started to audit any aspects of the care delivery at the home, on further discussion it was evident that she actually had been looking at care plans and staff records and identifying shortfalls in documentation; this just now needs to be properly recorded to provide evidence that a system is in place and to allow her to follow it through and ensure that where shortfalls are identified they are addressed in a timely manner. The managing director said they were planning to apply for Investors in People accreditation and a meeting had been arranged for the following week to take this forward. The company undertook a quality assurance survey for residents and their representatives in January 2007 and was able to provide an action plan of how they were addressing points raised through this. Abbey Hey Care Home Ltd DS0000005484.V347990.R01.S.doc Version 5.2 Page 25 Some relatives leave small sums of money as a “float” for residents to use for sundry items. This money is kept in the safe. It was reported that ledger sheets were kept for each resident and records kept of all transactions but these were not examined at this site visit. Staff supervision records showed that since the last random inspection in March 2007 most staff had received formal supervision once. The manager said she was going to ensure that supervision was carried out more frequently and had started to review staff training needs with each person as part of their first supervision session with her. A maintenance person is employed who works between the three homes owned by the company. Records showed that weekly checks had been made of the building and equipment in respect of fire prevention and health and safety. Staff were seen to be using safe working practices. The manager said that fire drills had been held at varying times to include members of staff working on different shifts during the day and night, but was unable to find the records to verify this. Since the last key inspection, some staff have attended training in infection control and the magnetic release mechanism on the fire door leading into a small lounge had been repaired. Bathrooms were noted to contain fairly large amounts of toiletries, which presented a risk to residents as potentially hazardous substances. In addition to this, residents should not be using communal toiletries but should be able to keep their own toiletries for their own personal use. Abbey Hey Care Home Ltd DS0000005484.V347990.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 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 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 2 X 3 2 2 2 Abbey Hey Care Home Ltd DS0000005484.V347990.R01.S.doc Version 5.2 Page 27 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 The manager must make sure that detailed care plans and risk assessments are in place to address all residents’ identified personal, social and health care needs, which contain all the information necessary to support staff in understanding the care they are required to deliver and how it is to be monitored. The manager must make sure that staff follow the correct procedures when administering and recording controlled medicines to ensure that no errors are made and an accurate record of the amount of medicines in the home is maintained. Timescale for action 15/11/07 2 OP9 13 15/11/07 Abbey Hey Care Home Ltd DS0000005484.V347990.R01.S.doc Version 5.2 Page 28 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 Refer to Standard OP3 Good Practice Recommendations The manager should make sure that all information gathered during the assessment process is considered when the resident is admitted to the home to ensure that all the residents’ needs are clearly identified. The manager should make sure that a daily statement is completed for all residents to provide an accurate record of the care given and their progress. The manager should make sure that any records relating to the care of residents are stored appropriately to maintain residents’ confidentiality. The manager should review all staff training records and bring them up to date. The manager should ensure that all staff receive supervision at least six times per year. The manager should ensure that all records listed in Schedules 3 and 4 of the Care Homes Regulations 2001 are maintained accurately and are available for inspection. 2 3 4 5 6 OP7 OP10 OP30 OP36 OP37 Abbey Hey Care Home Ltd DS0000005484.V347990.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Manchester Local Office 11th Floor, West Point 501 Chester Road Old Trafford Manchester M16 9HU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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