Inspection on 10/08/05 for Abbey Lodge Care Home

This inspection was carried out on 10th August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 Lodge Care Home 20/05/09

Abbey Lodge Care Home 04/12/08

Abbey Lodge Care Home 25/02/08

Abbey Lodge Care Home 13/06/06

Abbey Lodge Care Home 19/10/05

Abbey Lodge Care Home 25/01/05

Abbey Lodge Care Home 08/06/04

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Abbey The

Snydale Care Home

Larchfield Manor

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The Grove Waltham

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Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Abbey Lodge Care Home 10 Leeds Road Selby North Yorkshire YO8 4HX Lead Inspector Anne Prankitt Unannounced 10 and 11 August 2005 09:30 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 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 Lodge Care Home J53-J04 S44443 Abbey Lodge V234681 060705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Abbey Lodge Care Home Address 10 Leeds Road Selby North Yorkshire YO8 4HX 01652 653414 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) North Lincolnshire Care Ltd Miss Emma Louise Dodgson Care home only 23 Category(ies) of OP Old age (23) registration, with number DE(E) Dementia (23) of places Abbey Lodge Care Home J53-J04 S44443 Abbey Lodge V234681 060705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 25th January 2005 Brief Description of the Service: Abbey Lodge Care Home is owned by North Lincolnshire Care and was registered with the National Care Standards Commission in November 2003. The home provides personal care and accommodation for up to 23 older people, a number of whom have dementia. Abbey Lodge Care Home is located close to the centre of Selby and is situated in its own grounds. The accommodation provided is both in single and double rooms. The front door is locked for security and safety purposes and there is a stair lift for access to the first floor. Abbey Lodge Care Home J53-J04 S44443 Abbey Lodge V234681 060705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection lasted for approximately ten hours over one and a half days. Four hours’ preparation took place prior to the inspection. The registered manager, Emma Dodgson, and the representative of the responsible individual, Julie Harrowven, were present on the first day of the inspection when feedback was given. Further feedback was provided to the registered manager on the second day. A full tour of the building was undertaken, including the majority of the bedroom areas. Service users were spoken with, the views of visiting professionals were sought, and some discussion took place with care staff. In addition to this, records were looked at, including some care plans, staff recruitment and maintenance records. Time was also spent looking into some concerns that had been raised by the district nursing team. These related to alleged difficulties experienced in communication, which they felt could result in problems with the management of care. What the service does well: The environment is homely and comfortable. There are two nice sitting areas where residents can sit. Alternatively, they are free to sit in their own bedrooms if they wish. There is a library area in the main entrance hall, and a notice board where information for residents and their representatives is posted. Staff go about their duties in a quiet and unobtrusive way. They spoke to residents with respect. They are provided with training to help them care for the people who live at the home. The registered manager is supported on a weekly basis by a representative of the company. The representative provides updates to the Commission for Social Care Inspection following some of their visits so that the Commission is aware of how the home is running. Residents said that the food was good. They have a choice of menu, and the meals looked appetising. Residents can bring in their own belongings, and their bedrooms are individualised. One resident kept a photograph of their family in the communal sitting area, and enjoyed looking at this. Abbey Lodge Care Home J53-J04 S44443 Abbey Lodge V234681 060705 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: A letter was given to the registered manager about some matters that needed to be dealt with straight away. This included ensuring that hot water accessible to service users is kept at a safe temperature, that fire doors must not be wedged open, and that the registered manager must inform the care manager where certain residents’ needs had increased. Some concerns were raised by the district nursing team about communication which could result in their instructions not being properly followed. The care plans must be reviewed, and the levels of communication improved upon, so that information that staff need to know is clear, and staff must tell the nursing team more quickly where problems arise so that residents’ nursing needs can be attended to. Some aspects of the medication system and storage need to be improved upon, and further training provided for the staff who deal with medication on behalf of residents so that the systems in place can be improved upon. The arrangements in place when staff are employed at the home need to be improved upon so that all the necessary checks are in place. There is further work needed so that the heating is in full working order, without the use of secondary heating, and there are some matters regarding health and safety in the building that need to be actioned. These include confirmation that maintenance checks and follow up work have been completed. Abbey Lodge Care Home J53-J04 S44443 Abbey Lodge V234681 060705 Stage 4.doc Version 1.30 Page 7 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 Lodge Care Home J53-J04 S44443 Abbey Lodge V234681 060705 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Abbey Lodge Care Home J53-J04 S44443 Abbey Lodge V234681 060705 Stage 4.doc Version 1.30 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 standard(s) 3 Information gathered prior to admission is generally of good quality, and allows the home to confirm that the needs of service users can be met effectively. EVIDENCE: The registered manager explained that they carry out pre admission assessment for prospective service users. There was evidence of this seen in the care plans. One service user already placed at another local home had been referred to the home as an emergency by the care management team. There had been no pre admission assessment undertaken by the registered manager in this case because of the perceived lack of time available. The manager relied on the assessment from the care manager. Whilst the admission has been successful, the registered manager understands that a pre admission assessment should have been carried out in order that sufficient information could be gathered in order that an informed decision could be properly made as to whether the needs of the service user could be met. Abbey Lodge Care Home J53-J04 S44443 Abbey Lodge V234681 060705 Stage 4.doc Version 1.30 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 standard(s) 7,8,9 and 10 The written and verbal communication systems within the home need to be improved upon to ensure that service users’ needs are met effectively. The medication systems operating at the home do not adequately protect service users from the risk of error. EVIDENCE: Care plans, which consider the holistic needs of service users, are reviewed at the home on a monthly basis. Daily records are normally kept computerised. Due to problems with the system, staff were keeping hand written records, which were disorganised and difficult to follow. There is a senior staff communication book, which contained collective records about service users’ personal care. This is not permissible. The registered manager stated that this method of recording would cease with immediate effect. There was evidence to support that input had been provided by a falls assessor, and some equipment was in place where the waterlow risk assessment had identified that the service user was at risk from, or was suffering with, pressure sores. There was also good input provided by a psychiatrist for one service user. Despite containing some useful information, the care plans were not clearly set out, and lacked some information required in order to ensure that care Abbey Lodge Care Home J53-J04 S44443 Abbey Lodge V234681 060705 Stage 4.doc Version 1.30 Page 11 provision was consistent. This was discussed with the registered manager at the time of the inspection. For example: • • problems identified during the waterlow and nutritional risk assessments had not in all cases been followed up with a care plan to instruct staff as to the appropriate action to take in order to reduce the risk. the registered manager believed that service users who were cared for on a pressure relieving mattress did not require to be repositioned regularly in their bed. She said that the District Nurse had given this advice. It is recommended that key members of staff undertake training in pressure sore prevention and management, in order that the management of pressure sores can be better understood. One service user who suffered a pressure sore was seated in a position which was not conducive to the healing process. In addition to this, they had been supplied with a pressure relieving mattress, but not a seat cushion. The reason for this decision had not been recorded in the care plan. The registered manager agreed to discuss this with the district nurse. There are two service users at the home who have bed rails fitted to their beds. The bed rails are an integral part of the bed unit, and there was evidence in the file inspected to support that the district nurse had checked these in January 2005, and concluded that they were safe. However, the registered manager must, as part of the home’s risk assessment, appoint a suitable member of staff to check the bed rails on a regular basis, and record that this has been done. • • The district nursing team had raised concerns with the registered manager about the management by staff of some areas of care. They subsequently raised their concerns with the Commission for Social Care Inspection. These were taken into consideration during the inspection, and discussion was held with the registered manager about how improvements, where required, could be made. The areas of concern were as follows: • • Staff not always ‘chaperoning’ district nurses during visits, communicating problems or requesting feedback following visits Service users’ dressings ‘going missing’ The registered manager stated that dressings were held in service users’ bedrooms, but that these would not necessarily be stored in the same place in each room. She said that staff do accompany the district nurse to the room concerned. Discussion took place collectively with the registered manager and a member of the district nursing team about ways in which communication could be improved. The district nursing team have agreed to provide written feedback in their notes with regard to any orders that they wish staff to follow. • Service users’ notes ‘going missing’ J53-J04 S44443 Abbey Lodge V234681 060705 Stage 4.doc Version 1.30 Page 12 Abbey Lodge Care Home The registered manager had already acted on this concern, and had provided space within the office filing cabinet for storage. • Specialist hosiery not being applied as per district nurse instructions This was discussed with the registered manager, who gave assurance that this matter would be addressed with staff. • Conflicting information provided by different staff about service users’ nutritional status The documentation used to record fluid intake and output did not include information about the times at which food and fluids were provided to service users, and it was evident that these documents were not always shown to the district nurse on their visits. The registered manager has now redesigned the format in order that this additional information is included, and which will now be shown to the district nurses on their visits. • Delay in reporting the incidence of pressure sores to the district nurse team There was clear evidence in the care plan of one service user that there had been a delay of six days before a necrotic bed sore had been reported to the district nursing team. The registered manager had already looked into a delay in reporting to the district nursing team the bed sore suffered by a second service user. She had identified a lack of action by a member of staff in reporting this matter, and intends to address this further. She had also identified that the pressure sore had not been recorded within the care plan. The ‘turn charts’ implemented at the home did not require staff to report on the current skin condition on each turn. Again, the charts have been amended to include this information. A representative of the district nursing team have already identified that some improvements have been made since the concerns were raised. Reviews with the care manager are held annually, and in some cases more regularly where needs have altered and in the case where the care manager has been alerted. The care manager seeks the views of care staff when deciding whether nursing needs can continue to be met at the home with the support of the district nursing team, who are not themselves involved in the formal review. The registered manager acted quickly on the requirement that they must inform the care manager about three service users whose nursing needs had increased. Abbey Lodge Care Home J53-J04 S44443 Abbey Lodge V234681 060705 Stage 4.doc Version 1.30 Page 13 In the case of one service user who presents with challenging behaviour, the registered manager was actively engaging with the care manager. Observations made during the course of the inspection confirmed that service users are treated with respect by staff, and that their dignity is protected. Medication is supplied to the home in blister packs. There is a record kept of medication received from and returned to pharmacy. The following points were identified: • There was no controlled drugs cupboard. Staff said that any controlled drugs would be stored in a petty cash tin in the main drugs trolley. Diamorphine for use in a syringe driver (not yet in use) was stored in neither a controlled drugs cupboard, or in the medication trolley, or in the petty cash tin, but in a locked storage cupboard in the medication room. This was not secured to the wall. Fentanyl Patches 50mcg were stored in the main drugs trolley. Staff had been advised that they did not need to be stored as a controlled drug. • Confirmation was given that the above medication had been moved to the ‘petty cash’ tin stored within the medication trolley. • Oramorph Liquid 10mg/5mls was stored in an unlocked fridge in the locked medication room. Staff said that this was following the advice of a General Practitioner. Further advice regarding the above three issues has been sought from the Commission’s head pharmacist advisor who has confirmed that a Controlled Drugs cupboard must be provided at the home, and that Oramorph 10mg/5mls must be held securely. • • • Medication fridge temperatures had not been checked since May 2005. The temperature on the day of the inspection was too low There had been no risk assessment completed for one service user who chooses to part self medicate Not all staff who administer medication have completed accredited training. There was no record that the member of staff who was completing a medicine round on the morning of the inspection had completed any training. None of the medication administration records had been signed by the member of staff who had administered the medication to service users either on the morning, or the previous evening. This is not acceptable. • Abbey Lodge Care Home J53-J04 S44443 Abbey Lodge V234681 060705 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) EVIDENCE: None of the standards were assessed at this inspection Abbey Lodge Care Home J53-J04 S44443 Abbey Lodge V234681 060705 Stage 4.doc Version 1.30 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 standard(s) 16 Areas of concern, and suggestions for improvement, are accepted and taken seriously by the registered manager. EVIDENCE: The registered manager stated that the complaints procedure was normally posted on the communal notice board. However it was not. They said that a service user may have removed this, and agreed to arrange for it to be replaced. The procedure is also posted in service users’ bedrooms. However, it was incomplete, and did not give sufficient detail should a service user or their representatives wish to refer a complaint to the Commission for Social Care Inspection. Concerns have been raised with the Commission for Social Care Inspection by the District Nursing team. Details of significant findings can be found within standards 7 and 8 of this report. The registered manager demonstrated a commitment to improvement in those areas where it was identified that this was required. The district nursing team have intimated that some improvements have already been made. Abbey Lodge Care Home J53-J04 S44443 Abbey Lodge V234681 060705 Stage 4.doc Version 1.30 Page 16 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 standard(s) 22,25 and 26 Improvements have been made to the environment, but this requires further attention to ensure that service users are protected from unnecessary risk. EVIDENCE: There is a library area in the main entrance hall, and a notice board where information for service users and their representatives is posted. There is a choice of two pleasant sitting areas. The radiator in the occupied sitting area was not guarded. The hall and dining room carpet were badly stained, and needed to be cleaned. The representative of the responsible individual stated that this was already organised. There have been some improvements made since the last inspection: •All areas of the home are now accessible by stair lift. •95 of the corridor areas have been re carpeted. •Exposed hot water pipes identified at the last inspection have been boxed in. •Hand washing facilities have now been provided in the laundry. Abbey Lodge Care Home J53-J04 S44443 Abbey Lodge V234681 060705 Stage 4.doc Version 1.30 Page 17 Bedrooms are individualised. Several bedrooms are fitted with vinyl flooring, rather than carpet. The registered manager explained that this was in order that continence issues could be better managed, and the rooms kept properly clean. There were free standing radiators in some bedrooms used for secondary heating. The registered manager was instructed that secondary heating must only be used after being secured to the wall and guarded, and within a risk assessment framework. The registered manager decided that the secondary heating was not required at this point. It was removed from the bedrooms concerned. The representative of the registered provider explained that further work was required to the heating system, which had not yet been carried out. There is a possibility that secondary heating will be needed again prior to the works being completed. At a further meeting on 29 September 2005, the area manager, Julie Harrowven, gave assurance to the commission that should this be the case, secondary heating would be secured to the wall and guarded before being used. Works to fit individual thermostatic controls to those radiators that do not have this facility have not yet been carried out. However, the units have been purchased. There was a malodour to one bedroom. There was a flannel coated with faeces, and a soiled incontinence pad left in the room. The registered manager arranged for the room to be attended to. There is a bath aid in the downstairs bathroom. The room was being used inappropriately as a storage area. A previous recommendation was made that this equipment should be assessed by an occupational therapist. This has not yet been acted upon. The registered manager stated that none of the service users choose to use this bath, however the room was accessible to service users who may choose to use the toilet within. There was no hot water supply, soap or hand drying facilities in the first floor communal toilet. There was only one slide sheet available at the home, and which was shared between service users. This is not acceptable, and arrangements must be put into place to obtain additional slide sheets in order to reduce the risk from cross infection. Abbey Lodge Care Home J53-J04 S44443 Abbey Lodge V234681 060705 Stage 4.doc Version 1.30 Page 18 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29 and 30 Whilst there were sufficient numbers of staff available to meet the collective needs of service users, further staff training is needed to ensure that staff are appropriately skilled in the work that they perform. The process of staff recruitment is not sufficiently robust to ensure that service users are protected from unnecessary risk. EVIDENCE: There were three care staff plus the registered manager on duty, as well as domestic staff. There is a cook on duty Monday to Friday. The registered manager and two further staff assist with cooking at weekends when the cook is off duty. The cook and kitchen assistant has completed training in food hygiene. However, the registered manager must ensure that all staff who assist with the preparation of food have a certificate in Food Hygiene. The company provide training to staff in dealing with challenging behaviour. Staff have recently undertaken training in moving and handling. They have also attended a course on bereavement counselling. There are currently insufficient staff with an up to date first aid certificate to ensure that there is an appointed first aider available at all times. None of the staff have training in COSHH. The registered manager must address this. The recruitment procedures are not sufficiently robust: Abbey Lodge Care Home J53-J04 S44443 Abbey Lodge V234681 060705 Stage 4.doc Version 1.30 Page 19 • • • One member of staff had commenced employment prior to written references being returned, and there was no evidence to support that references were checked for their authenticity. CRB checks are not kept at the home from the point of employment until the next inspection. A CRB disclosure number is recorded on the staff file, but it was not possible to verify the point at which the CRB was applied for. There was no induction, supervision or training record available for inspection for one staff member who was employed in May 2005, and who was responsible for the administration of medication. Abbey Lodge Care Home J53-J04 S44443 Abbey Lodge V234681 060705 Stage 4.doc Version 1.30 Page 20 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32,35 and 38 The registered manager is supported and supervised by senior staff of the company in understanding her roles and responsibilities. The health and safety arrangements at the home are not sufficiently robust to ensure that service users are protected from unnecessary risk. EVIDENCE: Since the last inspection took place the manager has been successful in becoming registered with the Commission for Social Care Inspection. She is supported on at least a weekly basis by the area manager who acts as representative for the responsible individual, and who also carries out regular visits under regulation 26 of the act. Regular mandatory staff meetings take place. Discussion took place with regard to the need for the registered manager to be more involved in the day to day running of the home, in order that concerns, such as those raised by the district nursing team, can be recognised and acted upon in a proactive manner, and followed up through Abbey Lodge Care Home J53-J04 S44443 Abbey Lodge V234681 060705 Stage 4.doc Version 1.30 Page 21 rigorous supervision. One member of staff stated that the home was a nice place to work, that it was a nice quiet environment for service users, and that they were employed by a good provider. Other staff spoken with were happy with their working arrangements. There are no service users at the home for whom the registered manager is appointee, and there are no service users who handle their own finances. Some personal allowance is kept on behalf of service users. The records of three service users were reconciled with monies kept, which are held separately. There was a balance sheet missing for one service user. This should be found. The front door is kept locked with a key. A spare key is located in a break glass box next to the front door. The fire officer was contacted to check that they were satisfied with this arrangement. They confirmed verbally that this was satisfactory. The registered manager intends to discuss this further with the fire safety officer, who was due to visit the home in the near future. A number of hot water outlets accessible to service users were too hot, despite being fitted with valves. An immediate requirement was issued that these must be rectified. Others were not warm enough. Thermostatic valves have been purchased by the company, but have not yet been fitted. A number of maintenance records were seen, which were up to date. The following matters require further attention, and confirmation must be provided to the Commission within the action plan that they have been addressed: • • Emergency lighting – there were two failures recorded. The registered manager stated that it had been arranged for the electrician to repair these during the week of the inspection. In house fire alarm check – Whilst the records confirmed that these were checked on a weekly basis, there was a repeated fault recorded since November 2004 about the ‘dorgards’, with no remedial action having been taken. The doors concerned were wedged open by unauthorised means. The registered manager stated that the batteries required replacement. An immediate requirement was issued which instructed the registered manager that this must be carried out immediately. There was no fire alarm or emergency lighting maintenance certificate available for inspection. A copy of this must be provided to the Commission. Not all staff were receiving fire training at similar rates. A safety notice had been issued with regard to an incorrect flue termination from the Andrews gas boiler. There was no evidence available to confirm that remedial work had been completed. The fire panel showed a power fail fault. There was no evidence to confirm that water is stored above 60 degrees centigrade, or that the system has been chlorinated. J53-J04 S44443 Abbey Lodge V234681 060705 Stage 4.doc Version 1.30 Page 22 • • • • • Abbey Lodge Care Home • • The floor to the ground floor toilet was slippery when wet. This was discussed with the representative of the responsible individual, who attends to address this. The annual Portable Appliance Certificate was out of date from June 2005. Abbey Lodge Care Home J53-J04 S44443 Abbey Lodge V234681 060705 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 2 x x x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION x x x 1 x x 1 1 STAFFING Standard No Score 27 3 28 x 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x x x 2 x x 1 x x 1 Abbey Lodge Care Home J53-J04 S44443 Abbey Lodge V234681 060705 Stage 4.doc Version 1.30 Page 24 YES Are there any outstanding requirements from the last inspection? 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 7 Regulation 17 Requirement The registered manager must review the care plans, taking into consideration the following requirements: Timescale for action 30th September 2005 1) Collective records must not be kept 2) Problems identified during the waterlow and nutritional risk assessments must be followed up with a care plan to instruct staff as to the appropriate action to take in order to reduce the risk 3) The registered manager must, 11th as part of the home’s risk August assessment, appoint a suitable 2005 member of staff to check bed rails on a regular basis, and record that this has been done 2. 8 12, 13, 15, 16, 17(1)(a) Schedule 3(p) The registered manager must seek advice about the service user identified at the time of the inspection with regard to appropriate pressure relieving seating arrangements and equipment The registered manager must ensure that hoisery prescribed Abbey Lodge Care Home J53-J04 S44443 Abbey Lodge V234681 060705 Stage 4.doc Version 1.30 Page 25 11th August 2005 for the service user is applied according to instructions The registered manager must improve communication systems at the home in order that the incidence of pressure sores are reported to the district nurse without delay The incidence of pressure sores, their treatment and outcome, must be clearly recorded in the plan of care The registered manager must ensure that the care manager, where applicable, is informed where the health needs of service users have increased Controlled drugs must be stored in a locked facility which is secured to the wall, and which meets with the requirements of the Misuse of Drugs (Safe Custody) Regulations 1973 Oramorph Liquid must be held securely in locked facilities suitable for the storage of medication The temperature of the medicine refrigerator must be monitored daily, and the results recorded. Remedial action must be taken where the temperature reading is outside acceptable limits Service users who choose to self medicate should do so only following a risk assessment, which must be recorded, and reviewed on a regular basis Training must be provided for all staff who are responsible for the handling of medication Abbey Lodge Care Home J53-J04 S44443 Abbey Lodge V234681 060705 Stage 4.doc 3. 9 13, 17(1)(a) Schedule 3(k) 30th September 2005 10th August 2005 31st October 2005 Page 26 Version 1.30 4. 5. 22 25 23 13, 23 Medication administration records must be kept up to date at all times Bathroom and toilet areas must not be used for the storage of equipment The registered person is required to fit individual thermostats to all radiators in service user rooms which do not have them (Timescale of 31.05.05 not met) The bay window radiator to the sitting area in the lounge situated off the foyer must be guarded. In the interim. a risk assessment must be completed to ensure that service users are protected from unnecessary risk Additional slide sheets must be provided in order to reduce the risk from cross infection The carpets to the main foyer and dining area must be cleaned and kept clean The registered provider must provide an action plan as to how suitable washing facilities will be provided in the first floor toilet. 10th August 2005 10th August 2005 30th September 2005 31st October 2005 6. 26 12,13,23 15th September 2005 7. 29 19 Two written references must be obtained, and the registered manager must be satisfied that they are authentic, prior to the deployment of the staff member CRB checks must be kept at the home for all newly recruited staff until after the next inspection takes place All staff who assist with the preparation of food must have a certificate in Food Hygiene 11th August 2005 and maintained thereafter 8. 30 12,18 31st October 2005 Page 27 Abbey Lodge Care Home J53-J04 S44443 Abbey Lodge V234681 060705 Stage 4.doc Version 1.30 There must be sufficient staff with an up to date first aid certificate to ensure that there is a qualified first aider available on each shift Staff must receive training in the Control of Substances Hazardous to Health The registered manager must increase their supervision of the day to day operations of the home Accurate records must be kept of personal allowances kept on behalf service users, and if possible, the previous missing records located Hot water temperatures should be regulated at the point of delivery to 43 degrees centigrade (Timescale of 21.01.05 not met) The fault to the emergency lighting must be repaired Dorgards fitted to fire doors must be fully operational at all times. Fire doors must not be wedged open A copy of the up to date fire alarm and emergency lighting certificate must be provided to the Commission for Social Care Inspection Gaps in staff fire safety training must be addressed. The registered manager must liaise with the fire officer about the suitability of the current fire training provision. The decision with regard to frequency must be recorded in the fire safety risk assessment Abbey Lodge Care Home J53-J04 S44443 Abbey Lodge V234681 060705 Stage 4.doc Version 1.30 Page 28 9. 32 10,12, 24 30th September 2005 31st August 2005 10th August 2005 10. 35 20 11. 38 13,23 15th September 2005 11th August 2005 15th September 2005 The fault to the fire panel must be repaired The registered provider must investigate whether the works to the Andrews gas boiler have been completed, and provide evidence to the Commission that this is the case. Where the works have not been completed, remedial action must be taken Procedures must be introduced and maintained to ensure the risk from legionella is managed and recorded in the home (Timescale of 31.05.05 not met) The registered provider must ensure that systems are in place in order that the risk from slips due to the slippery ground floor communal toilet are eliminated 12. 13. 10th August 2005 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. 3. Refer to Standard 3 7 16 Good Practice Recommendations The registered manager should ensure that they complete a pre admission assessment in all situations where this is practicable Key members of staff should be provided with training in pressure sore prevention and management Full details of the complaints procedure, including contact details for the Commission for Social Care Inspection, should be available to service users and their J53-J04 S44443 Abbey Lodge V234681 060705 Stage 4.doc Version 1.30 Page 29 Abbey Lodge Care Home 4. 5. 6. 22 representatives It is recommended that a suitably qualified person assess the premises and facilities Abbey Lodge Care Home J53-J04 S44443 Abbey Lodge V234681 060705 Stage 4.doc Version 1.30 Page 30 Commission for Social Care Inspection Unit 4, Triune Court Monks Cross YORK YO32 9GZ 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 Lodge Care Home J53-J04 S44443 Abbey Lodge V234681 060705 Stage 4.doc Version 1.30 Page 31 - 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!