Inspection on 11/05/06 for Abbey Park

This inspection was carried out on 11th May 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Abbey Park 02/04/09

Abbey Park 08/04/08

Abbey Park 27/04/07

Abbey Park 06/10/05

Abbey Park 27/04/05

Abbey Park 27/09/04

Abbey Park 06/04/04

Abbey Park 02/12/03

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Abbey Park 49/51 Park Road Moseley Birmingham West Midlands B13 8AH Lead Inspector Brenda O`Neill Unannounced Inspection 11th May 2006 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Abbey Park DS0000017004.V292082.R01.S.doc Version 5.1 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 Park DS0000017004.V292082.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Abbey Park Address 49/51 Park Road Moseley Birmingham West Midlands B13 8AH 0121 442 4376 0121 449 1300 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) Mr M Salim Mr M Mughal Mrs Patrica Bannister Care Home 28 Category(ies) of Old age, not falling within any other category registration, with number (28) of places Abbey Park DS0000017004.V292082.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The home is registered to accommodate a maximum of 28 people for reasons of old age. Three named people, who were under 65 years of age at the time of admission can be accommodated and cared for in this Home for reason of physical disability or mental disorder, 25 OP, 2 PD and 1 MD That the Registered Manager obtains NVQ 4 in Care and Management and the Registered Managers Award or equivalent by September 2006. That the Registered Provider provides consultancy support until January 2006 specifically in setting up quality assurance tools in the home and providing support about staff management. 6th October 2005 Date of last inspection Brief Description of the Service: Abbey Park is a home registered for 28 older people and has both single and shared bedroom accommodation. It is situated in the Moseley area of Birmingham in a residential street within a ten-minute walk of Cannon Hill Park. Within walking distance there is access to bus services that will take you to the centre of Birmingham or to Acocks Green or, on another route to Birmingham and to Druids Heath. The home is an adapted building over three floors. The third floor is accessed by a stair lift and there is a passenger lift to the second floor. The home has three lounges and two dining areas. One of the dining areas is reserved for service users that smoke. There is an assisted bathing facility on the ground floor and an assisted shower on the first floor. The home has a large accessible enclosed garden to the rear of the property. The home has a ramped access at the front of the house but this is not the main access to the building and there is ramped access at the rear of the building. A small amount of car parking is available at the side of the home. The fees at the home range from £314 .00 to £346.00 per week. Abbey Park DS0000017004.V292082.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and carried out by two inspectors over one day in May 2006. During the course of the inspection a tour of the premises was carried out, three resident and three staff files were sampled as well as other care and health and safety documentation. The inspectors spoke with the manager, briefly to the proprietor, two staff members and nine of the 23 residents. Prior to the inspection the inspector received a completed pre inspection questionnaire that included information about the home, residents and staffing, eight completed relatives comment cards and three completed resident questionnaires all of which were positive in their comments. What the service does well: The home had a very friendly and welcoming atmosphere. Throughout the course of the inspection it was evident that staff had good relationships with the residents. All the residents spoken with were satisfied with the service they were receiving and were very positive in their comments about the staff team. Comments received about the home prior to the inspection included: ‘We are satisfied with the care here.’ ‘I am very satisfied with the care given I cannot fault anything in the welfare given.’ ‘Good care.’ ‘I am very satisfied.’ ‘Very impressed with the quality of care there, also the staff are always very helpful.’ The home had maintained a core group of staff who had worked there for a considerable amount of time, which was very good for the continuity of care of the residents. Prospective residents were able to visit the home prior to admission and assess if it was the right home for them. Once admitted to the home there were no restrictions on visitors within reasonable hours. There was evidence that the health care needs of the residents were being identified, followed up and monitored. The medication system was safe and well managed. There did not appear to be any rigid rules or routines in the home and there were some activities offered that residents could take part in if they wished. Abbey Park DS0000017004.V292082.R01.S.doc Version 5.1 Page 6 The menus seen offered a good variety of food and were nutritious and the residents spoken with were very happy with the catering arrangements at the home. Cultural and medical diets were being catered for. Several of the staff were qualified to NVQ level 2 or above. The manager was very knowledgeable about the needs of the residents. What has improved since the last inspection? What they could do better: The service user guide for the home needed to be updated and made available for prospective residents to the home, so that they would be aware of the facilities on offer. A copy also needed to be issued to the current residents. The contracts/terms and conditions of residence at the home needed to be updated and include all the necessary information. To ensure staff were aware of the needs of prospective residents the manager needed to obtain a copy of the social worker’s assessment prior to the admission of residents to the home. All residents needed to have comprehensive care plans and risk assessments that identified all their needs and how these were to be met by staff and how any risks were to be minimised. There needed to be discussions with the residents as to their likes, dislikes and preferences in relation to activities and these needed to be detailed on care plans with details as to how these were to be facilitated by staff. There also needed to be evidence that residents who could not or did not want to take part in group activities were given one to one time. To ensure the protection of the residents the manager needed to amend the adult protection procedure in the home and ensure it complied with the multi agency guidelines. Abbey Park DS0000017004.V292082.R01.S.doc Version 5.1 Page 7 Improvements were needed to the induction training for new staff to ensure they were equipped with the skills and knowledge necessary to fulfil their roles. The manager also needed to ensure there was a system in place to easily identify what training had been undertaken by staff. The home needed to have in place a formal system for monitoring the quality of the service offered based on seeking the views of the residents with a view to continuous improvement. The proprietor for the home needed to undertake unannounced visits to oversee the management/conduct of the home and prepare reports on the outcomes of the visits. These reports need to be made available for inspection. Although the home was generally comfortable some issues were raised that needed to be addressed to ensure the residents lived in a safe environment, for example, additional radiator covers and access to the emergency call system. Some areas of the home were in need of decoration and some furnishings needed to be replaced. 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 Park DS0000017004.V292082.R01.S.doc Version 5.1 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 Park DS0000017004.V292082.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 The quality in this outcome area is poor. This judgment has been made using available evidence including a visit to this service. The home needed to have available adequate information for any prospective residents to ensure they could make an informed decision as to whether the home could meet their needs. Residents needed to be issued with contracts that included all the current terms and conditions of residence at the home. The needs of prospective residents taken into the home were not always known by staff and therefore the home was not able to ensure all individual needs would be met. EVIDENCE: There was a service user guide available at the home however residents had not been issued with a copy and there were no copies available for prospective residents. The document also needed to be updated and include all current information and include some of the residents’ views on the home. Three resident files were sampled. The home did undertake their own assessment of needs for the residents however this was generally done on the Abbey Park DS0000017004.V292082.R01.S.doc Version 5.1 Page 10 pre admission visit and the information gained varied. It was evident from all the files sampled that social workers had been involved in the admission process but copies of their assessments had not been obtained by the manager. The manager needed to ensure she obtained copies of the full social work assessment to ensure they had as much detail as possible about the needs of prospective residents. After admission to the home another assessment was completed and this included information on levels of dependency and the areas where residents needed assistance or supervision with tasks. One of those seen included information about the residents diet in relation to his cultural needs and the possible language barriers there may be. It was evident from one file that when one of the residents was admitted to the home there was a diagnosis of dementia which is outside the registration category for the home. This individual had been at the home for over two years at the time of the inspection and was admitted by the previous manager. It was evident the condition was deteriorating however the present manager was doing as much as she could to get the required help, for example, input from the psycho geriatrician and liaising with the social worker. The present manager needed to be mindful that for any future admissions outside the registration category of the home she must apply to the CSCI for a variation detailing how the needs of the individual would be met. Residents were being issued with contracts that included details of some of the terms and conditions of residence however the fees to be paid were not included. It was also noted that the contracts were very out of date and mentioned the Registered Homes Act which is not the current legislation regulating care homes and also such things as specific visiting times which were no longer applicable in the home. Abbey Park DS0000017004.V292082.R01.S.doc Version 5.1 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The care plans did not detail how the individual needs of the residents were to be met and strategies for managing risks were not clearly identified. Health care needs were being identified and followed up. The medication system was well managed and safe. EVIDENCE: Three residents care plans were sampled. The home was using a booklet entitled ‘Assessment for good care planning.’ The booklets included numerous areas and gave some information about each resident’s history both personal and medical. There were risk assessments for mental and physical health, behaviour, falls, nutrition and pressure areas. There was also a section for needs and preferences. These booklets were purely an assessment tool and did not identify individual needs and document how staff were to meet these. The assessments that had been undertaken by staff in the home had identified some of the individual needs of the residents but these had not been carried forward to any care plans and there were no specific instructions for staff as to how individual needs were to be met. Care planning was discussed with the Abbey Park DS0000017004.V292082.R01.S.doc Version 5.1 Page 12 manager and it was determined that this issue been raised at the previous inspection. Following that inspection the manager had completed two very detailed care plans for two of the residents. These were viewed and included a lot of detail of the individual needs of the residents and how their needs were to be met. These care plans were not being used at the time of the inspection. The manager was advised that comprehensive care plans needed to be completed for all the residents and be available to staff at all times. There were numerous risk assessments in the assessment booklets being used however these were not always fully completed, for example, one of the tissue viability assessments and on occasions where a resident had been identified as at risk there was no documentation as to how the risk was to be minimised, for example, there was evidence that one resident could become agitated and wandered but there was no risk assessment in relation to this. There was no evidence of any manual handling risk assessments and the falls risk assessments did not document what action was to be taken by staff if the resident did fall. There was evidence that the health care needs of the residents were being identified, followed up and monitored. There was evidence of doctors visits, dental appointments, chiropody treatment and so on and also of more specialised input where necessary, for example, psycho geriatricians and physiotherapists. Where possible residents were being weighed and records of this were being kept. The manager needed to ensure there was a system in place to monitor the weight of any residents who were unable to stand on the scales, for example, arm circumference. There was evidence of some personal care needs being met on the daily records however as the spaces on the daily records were very limited staff were not writing a great deal. It was strongly recommended that an additional information sheet was included on the residents’ files to enable staff to write more detailed information where necessary. The system for administering medication was generally well managed with only minor requirements being made. Since the last inspection storage for controlled medication had improved however the home needed to have a controlled drug register on site. Medication that was audited was found to be correct. Eye drops and creams needed to be dated on opening and the temperatures for the medication fridge needed to be recorded daily to ensure the fridge was working efficiently. Residents, rights to privacy and dignity appeared to be upheld. Staff addressed residents appropriately and residents could spend time privately in their rooms if they wished. Bedroom doors were lockable and residents were able to have keys if they wished and all double rooms had adequate screening. The completed comment cards received from relatives prior to the inspection indicated that residents could meet with their relatives in private. Abbey Park DS0000017004.V292082.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. There were no rigid rules or routines in the home and there were some activities available for residents to take part in if they wished but they did not meet with the expectations of all the residents. The arrangements for visiting the home enabled visitors to come at any reasonable hour. The catering arrangements at the home generally met the needs of the residents. EVIDENCE: All the residents spoken with were satisfied with the care they were receiving and confirmed they spent their time as they chose. There was a documented activities programme, which included such things as bingo, drawing, reminiscence and chair aerobics. Individual activity records were being kept with comments as to whether the individual had enjoyed the activity. Residents spoken with had mixed views about the activities and the programme did appear quite repetitious. There needed to be discussions with the residents as to their likes, dislikes and preferences in relation to activities and these needed to be detailed on care plans with details as to how these were to be facilitated by staff. There also needed to be evidence that residents who could not or did not want to take part in group activities were given one to one time. Abbey Park DS0000017004.V292082.R01.S.doc Version 5.1 Page 14 There did not appear to be any restrictions on visiting within reasonable hours. There was evidence on the daily records of frequent visitors to the home and that residents went out with their relatives. Visitors were seen to come and go throughout the inspection and appeared to be made welcome. Good relationships were evident between staff and visitors. It appeared that residents were encouraged to exercise choice and control over their lives in such things as choosing what they did during the day, what to wear, when to get up and go to bed and what to eat. Residents had been encouraged to personalise their rooms to their choosing and personal effects were seen in all the bedrooms. All the residents spoken with were generally happy with the catering arrangements at the home. One resident did comment she would like sausage and bacon at teatime to put in a sandwich and a milky drink at bedtime. This was discussed with the manager who stated she would look into this but assured the inspectors that all residents were offered a milky drink. The food records evidenced a good variety of foods being served to the residents and diets in relation to culture and medical needs being catered for. There were several alternatives available for the residents if they did not want what was on the menu. The inspectors had lunch with the residents and the meal was well cooked and presented. One resident was seen to have sandwiches, which he stated was his choice as he was not keen on cooked meals. When residents did not eat what they were given an alternative was offered and there was also a variety available for pudding. Abbey Park DS0000017004.V292082.R01.S.doc Version 5.1 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. There was an appropriate complaints procedure for the home and residents appeared confident that the manager would address any issues they raised. To ensure the protection of the residents the manager needed to amend the adult protection procedure in the home and ensure it complied with the multi agency guidelines. EVIDENCE: The home had not received any complaints since the last inspection and none had been lodged with the CSCI. There was a complaints procedure in the home and this only required a very minor amendment as the NCSC was still mentioned. The completed relative comment cards received prior to the inspection all confirmed that the relatives were aware of the complaints procedure and that they had not made any complaints. Residents spoken with stated they would have no problems raising any issues with the manager and were confident that they would be resolved. There were policies and procedures on site for adult protection. Part of these included a checklist for staff to follow if abuse was suspected and this stated ‘investigate in a robust manner’, which is contradictory to the multi agency guidelines, which needed to be followed in the suspicion of abuse. This checklist needed to be removed from the policies. There was also a reporting policy for staff and this did comply with the multi agency guidelines. The manager was advised she needed to obtain a copy of the multi agency Abbey Park DS0000017004.V292082.R01.S.doc Version 5.1 Page 16 guidelines for adult protection and these should run alongside the home’s procedures. There was also a whistle blowing policy on site. Abbey Park DS0000017004.V292082.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24, 25, 26 The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The home was generally comfortable. Some issues needed to be addressed to ensure the residents lived in a safe environment. EVIDENCE: There had been no changes to the layout of the home since the last inspection. The home was found to be generally comfortable and residents appeared happy with the environment. The manager stated that whenever a room was vacated it was redecorated before another resident was admitted. There was general redecoration needed throughout the home, for example, torn borders and chipped paintwork. It was also noted that the carpet outside the kitchen was badly worn and in need of replacing. Abbey Park DS0000017004.V292082.R01.S.doc Version 5.1 Page 18 At the time of the inspection the exterior window frames were being renovated. The grounds to the home were quite large and there was garden furniture available for the residents. It was noted that some of the paving slabs were uneven and a potential tripping hazard for the residents and staff. During the tour of the home it was noted that the self-closure on the kitchen door was broken and it was wedged open. In addition there was a fault on one of the fire doors on the second floor of the home. Immediate requirements were left at the home in respect of these. Prior to writing this report the manager had written to the inspector stating these issues had been addressed. The home had adequate communal space with three lounges and one dining room. One of the lounges was a designated smoking area. The dining room was quite small but some residents chose to eat in the lounges and there was also a table in the smoking room as some residents preferred to eat in there. It was noted that there was no emergency call point in the dining room. Also the window in the dining room did not have a restrictor fitted and could swing right out and would have been very easy for someone to get in from outside. This needed to be risk assessed and appropriate action taken to ensure the safety of the staff and residents. The décor and furnishings in these rooms were of an acceptable standard. There were adequate numbers of toilet, bathing and shower facilities throughout the home. One of the bathrooms had a hoist and the shower was floor level, both of these rooms allowed for assistance from staff. Some of the bedrooms also had en-suite facilities. There was a variety of aids and adaptations throughout the home including, ramped entrance, shaft and stair lift, hoist, transfer board, special cutlery and emergency call system. As mentioned there was no emergency call point in the dining room and not all call points were accessible from the bathing facilities. There were some hand and grab rails but in some corridors there were no handrails and in others they were only to one side. Wherever possible handrails should be available on both sides of the corridors to assist residents with mobility difficulties. Bedrooms in the home were a mix of singles and doubles, varied in size and some had en-suite facilities. Not all the required furnishings were available in all the rooms and one resident stated she would like another chair in her bedroom. The manager needed to audit all the rooms against the National Minimum Standards and discuss with the residents their requirements. Where residents did not want all the furnishings a record of this needed to be made in the relevant personal file or alternatively make arrangements to supply any additional furnishings. It was also noted that some of the armchairs in the bedrooms were stained and worn these needed to be replaced. Abbey Park DS0000017004.V292082.R01.S.doc Version 5.1 Page 19 All rooms in the home were centrally heated and the majority of radiators had been covered however there were two that were not, one in a bathroom the other in a toilet. During the tour of the home it was noted that some of the hot water outlets in the showers were very hot and well in excess of the required 43 degrees. An immediate requirement was left at the home in relation to this. Prior to the writing of the report the inspector received written confirmation from the manager that this had been addressed. Not all the extractor fans in the en-suites and communal facilities were working at the time of the inspection and this needed to be addressed. The home was generally clean and odour free with the exception of one bathroom where the tiles were very dirty and another where the bath panel needed cleaning. The systems in place for infection control were generally good. There was liquid soap and disposable towels in all communal facilities, there was a system in place for the disposal of clinical waste, protective clothing was available for staff and the laundry had a sluice washing machine installed. To further improve infection control in the home the underside of the bath hoist needed to be thoroughly cleaned. The kitchen was clean and tidy with all the appropriate checks in place and fly screens had been installed since the last inspection. Abbey Park DS0000017004.V292082.R01.S.doc Version 5.1 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, 30 The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Adequate staffing levels were being maintained to meet the needs of the residents. Arrangements for staff induction were inadequate to ensure they are able to deliver adequate and appropriate care. Recruitment procedures were robust and protected the residents. EVIDENCE: There had been little staff turnover at the home and several of the staff had worked there for a considerable amount of time, which was good for the continuity of care of the residents. The home was fully staffed at the time of the inspection. Staffing levels had improved since the last inspection and the manager was ensuring there were four staff on duty every morning, three during the afternoon and evening and two waking night staff. The manager’s hours were supernumery to the care staff rota and the home also employed cooks and domestic assistants. The recruitment files for three staff were sampled and found to be complete. All included, application forms, two written references, proof of I.D. and an enhanced CRB disclosure that had been obtained prior to the staff commencing their employment. It was recommended that the manager keeps interview records when recruiting new staff and include in these any discussions about gaps in employment. Abbey Park DS0000017004.V292082.R01.S.doc Version 5.1 Page 21 The induction training for new staff needed to be improved. It consisted of a checklist that was not always signed or dated and only covered basic areas. The manager stated that new staff shadow an experienced member of staff when they are first employed. All new staff needed to have induction training in line with the specifications laid down by skills for care and completed within the first twelve weeks of employment. The pre inspection questionnaire stated that all regulatory training had been ongoing over the last year and more training was planned. Topics included fire training, moving and handling, infection control, health and safety and food hygiene. It was difficult to determine if all staff had had all the required training and that it was up to date as there was no training matrix for the home. The manager needed to develop a training matrix for the home that identified who had had what training, and when, as a way of checking that all staff were up to date. Over fifty percent of staff were qualified to NVQ level 2 or above which was to be commended. Abbey Park DS0000017004.V292082.R01.S.doc Version 5.1 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, 32, 33, 35, 36, 37, 38 The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The manager ensured the smooth running of the home in a competent manner and in the best interests of the residents. The home needed to have in place a formal system for monitoring the quality of the service offered based on seeking the views of the residents. EVIDENCE: The manager of the home had been employed there since 2004 and throughout the inspection demonstrated a good knowledge and understanding of the needs of the residents in her care and the running of a residential unit. She had very good relation ships with the proprietor and stated he was very supportive. She demonstrated a commitment to further improving the home and a willingness to meet the requirements made throughout the inspection. Abbey Park DS0000017004.V292082.R01.S.doc Version 5.1 Page 23 This was evidenced by the speed in which she responded to the immediate requirements left at the home. There appeared to be good relationships within the staff team and there were clear lines of responsibility. The home was run with an open and inclusive atmosphere and there was a very friendly environment. Staff meetings were taking place. There were several audits taking place in the home to monitor the quality of the service for example, cleaning and hygiene audits and health and safety audits. A resident questionnaire had been developed but this had not been used at the time of the inspection. The manager needed to ensure there was a formalised quality monitoring system in place at the home based on seeking the views of the residents with the aim of continually improving the service. The manager was handling the personal allowance for some of the residents. A specific account had been set up by the proprietor for personal allowances to be paid into where there was no other option. The proprietor then drew the money and passed it over to the manager. All residents had individual books where this was recorded. Amounts were acknowledged as being received, details of expenditure were entered and receipts were available. Two staff signed for any transactions made on behalf of the residents. There was some evidence that staff supervision sessions were taking place but this was not to the required frequency. There was no evidence that the proprietor was making any unannounced visits to the home to oversee the management/conduct of the home. It is a requirement that these visits takes place and that the proprietor inspects the environment, samples administration and speaks to the residents and then prepares a report on the outcome of the visit. Health and safety was generally well managed in the home. There was evidence on site of the servicing of most of the equipment with the exception of the stair lift and this was faxed to the inspector within days of the inspection taking place. The in house checks on the fire system were up to date and staff had received fire training. There was a premises risk assessment on site, which covered all the required areas. Accident and incident recording and reporting were seen to be appropriate. Abbey Park DS0000017004.V292082.R01.S.doc Version 5.1 Page 24 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 1 2 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 2 3 2 X 2 2 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 2 2 3 Abbey Park DS0000017004.V292082.R01.S.doc Version 5.1 Page 25 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 OP1 Regulation 5(1) Requirement The service user guide must be updated and include all the relevant information. Timescale for action 01/07/06 2. OP2 5(1) Copies of the service user guide must be issued to all current residents or their representatives and made available to prospective residents. The contract/terms and 14/07/06 conditions of residence for the home must be updated and include all the relevant information. The updated document must be issued to all current residents and to any new residents at the point of admission to the home. The manager must ensure she 01/07/06 obtains a copy of the social work assessment prior to the admission of any residents to the home. All residents must have care 01/08/06 plans that clearly detail how all their needs in respect of health and welfare are to be met by staff. DS0000017004.V292082.R01.S.doc Version 5.1 Page 26 3. OP3 14(1) 4. OP7 15(1) Abbey Park 5. OP7 13(4)(c) 6. OP7 13(5) 7. OP8 12(1)(a) 8. OP8 12(1)(a) 9. 10. OP9 OP9 13(2) 13(2) This remains outstanding since 31/05/05. There must be risk assessments in place for any identified risks in relation to the residents. These must clearly detail how the risks are to be minimised by staff. All residents must have manual handling risk assessments that detail how the residents are to be assisted in the event of a fall. The manager must ensure that all the risk assessments being used at the home in relation to the residents’ health care are fully completed. Alternative methods of monitoring the weights of residents who cannot stand on the scales must be put in place. A controlled drug register must be purchased. Eye drops and creams must be dated on opening. 01/07/06 01/07/06 01/07/06 01/07/06 01/07/06 14/06/06 11. OP12 12(3) 16(2)(m) The temperatures of the medication fridge must be monitored. 01/08/06 The manager must ensure that the range of activities available in the home is discussed with the residents. Individual likes dislikes ad preferences in relation to leisure must be detailed on care plans and include how these are to be facilitated by staff. There must be evidence that residents who do not wish to take part in group activities are given one to one time. The manager must ensure there is a copy of the multi agency guidelines for adult protection on site. DS0000017004.V292082.R01.S.doc 12. OP18 13(6) 01/07/06 Abbey Park Version 5.1 Page 27 13. 14. 15. 16. OP19 OP19 OP19 OP20 23(2)(d) 23(2)(b) 13(4)(c) 13(4)(c) 17. OP22 13(4)(c) The adult protection procedures in the home must be amended to ensure they comply with the multi agency guidelines. All areas of the home must be reasonably decorated. The worn carpet outside the kitchen must be replaced. The uneven paving slabs in the garden must be relayed. The window opening in the dining room must be risk assessed and appropriate action taken to ensure the safety of the residents and staff. Call alarms must be accessible from all bathing facilities. An emergency call point must be installed in the dining room. Wherever possible handrails must be fitted to both sides of the corridors in the home. All bedrooms must be audited against the National Minimum Standards for furnishings and fittings. Where residents choose not to have all the required furnishings a record must be made of this. Arrangements must be made to supply any additional furnishings required by the residents. Any worn or badly stained armchairs in the bedrooms must be replaced. All radiators in the home must be guarded. All extractor fans must be in working order. The tiles in the bathroom where the hoist is located must be thoroughly cleaned. The bath panel in the bathroom must be cleaned. 01/09/06 01/09/06 01/07/06 14/06/06 01/08/06 18. 19. OP22 OP24 23(2)(n) 16(2)(c) 01/10/06 01/09/06 20. 21. 22. 23. OP24 OP25 OP25 OP26 16(2)(c) 13(4)(c) 23(2)(b) 13(3) 01/08/06 01/07/06 01/07/06 14/06/06 Abbey Park DS0000017004.V292082.R01.S.doc Version 5.1 Page 28 24. OP30 18(1)(c) 25. OP33 24(1) 26. 27. OP36 OP37 18(2) 26 The underside of the bath hoist must be thoroughly cleaned. The registered manager must produce a matrix of the staff training and a copy must be sent to the Commission. This remained outstanding since 15/06/05. The home must have a system in place for monitoring the quality of the service offered based on seeking the views of the residents. All care staff must have recorded supervision not less than 6 times a year. The responsible individual for the home must visit the home unannounced at least monthly and prepare a report about the conduct of the care. These reports must be made available for inspection. 01/08/06 31/08/06 01/07/06 01/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP8 OP29 Good Practice Recommendations It is recommended that the home has an additional information sheet available with the daily records. It is recommended that the manager keeps records of interviews when recruiting staff and includes any discussions about gaps in employment. Abbey Park DS0000017004.V292082.R01.S.doc Version 5.1 Page 29 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Park DS0000017004.V292082.R01.S.doc Version 5.1 Page 30 - 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. 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