Inspection on 27/04/07 for Abbey Park

This inspection was carried out on 27th April 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 Park 02/04/09

Abbey Park 08/04/08

Abbey Park 11/05/06

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 Key Unannounced Inspection 27th April 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 Park DS0000017004.V334568.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 Park DS0000017004.V334568.R01.S.doc Version 5.2 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 Patricia Bannister Care Home 28 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (28) of places Abbey Park DS0000017004.V334568.R01.S.doc Version 5.2 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, of which 6 for the category of DE(E). 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. 11th May 2006 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.V334568.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors carried out this key inspection over one day in April 2007. During the course of the inspection a tour of the premises was undertaken, three files for the people who live in the home and three staff files were sampled, as well as other care and health and safety documentation. During the day the inspectors had lunch with the people living in the home and made observations of the care practices. The inspectors spoke with the manager, the proprietor, two staff members and seven of the people living in the home. In November 2006 a random inspection was carried out at the home to assess the progress being made on some of the requirements made following the key inspection on 11/05/06. Areas assessed during this visit were care planning, residents’ risk assessments, health care, the environment and health and safety. The findings from this visit will be detailed in this report. The home had not had any complaints since the last key inspection and none had been lodged with the Commission. What the service does well: The atmosphere in the home throughout the course of the inspection was very relaxed. All the people living at the home that were seen or spoken with were very content. There were no rigid rules or routines in the home and the people living there spoke to the inspectors about making choices and spending their time as they chose. One person living at the home stated, ‘they are taking pretty good care of me.’ Visits by health care professionals were recorded on separate sheets so they were easy to track and they did cross reference to the daily records. The records indicated that staff identified any health care issues, these were then followed up and monitored. There were activities available for the people living in the home if they wished to take part. Records sampled indicated that these varied from one person to another. There were no restrictions on visitors to the home within reasonable hours. People living at the home could go out with relatives or friends if they wished. All the people living at the home who were spoken to on the day of the inspection were very happy with the meals being served. It was evident that staff knew what the people who lived there liked and meals varied accordingly. Abbey Park DS0000017004.V334568.R01.S.doc Version 5.2 Page 6 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 people living there. The people living at the home were very comfortable in the presence of the staff and the manager which would give them the confidence to raise any issues they may have. Recruitment procedures were robust and safeguarded the people living at the home. The home was generally well maintained and safe and provided the people living there with a comfortable and homely environment in which to live. The manager ensured the smooth running of the home in a competent manner and in the best interests of the people living there. What has improved since the last inspection? What they could do better: To ensure staff were aware of the needs of people going to live in the home the manager needed to obtain a copy of the social worker’s assessment prior to their admission to the home. All the people living in the home 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. Abbey Park DS0000017004.V334568.R01.S.doc Version 5.2 Page 7 To ensure the protection of the people living in the home the manager needed to amend the adult protection procedure in the home and ensure it complied with the multi agency guidelines. The registered person must ensure that all staff have completed all the appropriate training in safe working practices. This will ensure the safety of the people living at the home. 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 people living there with a view to continuous improvement. This will ensure the service offered in the home is kept to an acceptable standard for the people living there. To ensure people living at the home are safe guarded 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. To further enhance the safety of the people living at the home the manager must ensure that fire drills are undertaken every six months. 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 Park DS0000017004.V334568.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 Park DS0000017004.V334568.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): 1, 2 and 3. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There was adequate information for people wanting to live in the home to ensure they could make an informed decision as to whether the home could meet their needs. The assessment process for the people wanting to live in the home did not ensure all their individual needs were known to the staff prior to admission. EVIDENCE: The files for three people admitted to the home since the last inspection were sampled. It was evident that social workers had been involved in the pre admission assessments as there were care plans drawn up by them in place. Copies of the full social work assessment had not been obtained. 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 people wanting to live at the home. Abbey Park DS0000017004.V334568.R01.S.doc Version 5.2 Page 10 The manager of the home undertook her own assessments however these were not adequately detailed, for example, there was no evidence of why the individuals needed residential care and it was not evident from one that the person may have had specific cultural needs. The home had recently had a variation so they could accommodate six people with dementia. Two of the files sampled were for people diagnosed with dementia. There was nothing in the pre admission assessments that detailed how their dementia affected them or what additional needs they may have in relation to this. At the time of the random inspection the contract /terms and conditions of residence had been updated and included all the relevant details. Copies of the new contracts were evident on the files sampled. Also at the time of the random inspection the service user guide had been updated and included all the necessary information however copies of this had not been given to all the people living at the home. At the time of this inspection this had been addressed and service user guides were seen in the bedrooms. Abbey Park DS0000017004.V334568.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. This judgement has been made using available evidence including a visit to this service. The care plans did not detail how all the individual needs of the people living in the home were to be met and strategies for managing risks were not always clearly identified. Health care needs were being identified and followed up. The medication system was generally well managed and safe. EVIDENCE: At the random inspection new care plans had been drawn up for all the people living in the home and these were much more informative than the care plans previously in place. The care plans generally highlighted all the needs of the people living there and stated how staff were to meet them. At the time of this inspection the care plans for three new people admitted to the home were sampled. The content of the care plans was variable. On admission to the home an assessment of the individuals’ needs had been undertaken which covered several areas of their lives, for example, social, Abbey Park DS0000017004.V334568.R01.S.doc Version 5.2 Page 12 hygiene and dressing, communication, behaviour and sleeping. These were used to inform the care plan. Some areas of the care plans were very well detailed, for example, one of the individuals was very deaf and there was a very detailed description of how staff were to communicate with the person. Staff were observed communicating with this person at lunchtime and were following the care plan. Issues around this individual’s diet were also very well detailed. There were issues over lack of appetite and the person being under weight. The care plan included a lot of detail of how staff were to try and over come the issues and to highlight any concerns to management. Other areas were either not included or were very vague, for example, there was no detail of how any cultural needs were to be met, the care plans for personal care needs were generic and needed to be individualised for each person and detail what people were able to do for themselves. There were some details of when people preferred to go to bed and get up and if they were able to make these decisions on their own or not. The care plans needed to include the abilities, likes, dislikes and preferences of the people living at the home. This would ensure their care needs were met in the way they preferred. There was some evidence of care plans being reviewed monthly but not all areas were included. At the time of the random inspection the risk assessments in place for the people living at the home had improved. All the files sampled at this inspection showed several risk assessments had been undertaken including nutritional and tissue viability assessments. Where a risk had been identified there was a corresponding care plan. Manual handling risk assessments had been undertaken since the last inspection but these did not detail any specific handling methods. The manager had put in place a procedure for staff to follow in the event of any of the people living in the home having a fall however it did not identify what handling methods were to be used for each person. This information needed to be included on each individual file, as it will vary from person to person. All the files sampled included personal risk assessments. The majority of these were generic and in place for all residents, for example, bathing and smoking. Again these needed to be individualised and include any specific risks for that particular person. For example, one of the people living at the home had been identified as having a history of falls but there was no risk assessment in place for this. Visits by health care professionals were recorded on separate sheets so they were easy to track and they did cross reference to the daily records. The records indicated that when staff identified any health care issues these were then followed up and monitored. There was evidence of visits from G.Ps, Abbey Park DS0000017004.V334568.R01.S.doc Version 5.2 Page 13 district nurses, residents being admitted to hospital when necessary and dental check ups. Where necessary more specialised health care input was obtained, for example, community psychiatric nurses. Where possible the people living at the home were being weighed on a monthly basis and records of this were being kept. The system in place for administering medication had not changed and was generally well managed. Only senior staff administered medication and all had undertaken appropriate training. The medication for four of the people living in the home was audited. Some discrepancies were noted where the amounts of medication remaining in the home did not correspond with the amount that had been delivered to the home and what had been administered. The manager needed to have in place a system for auditing the staff before and after drug rounds to try and identify how the errors were being made and to ensure staff were competent in medication administration. It was also noted that copies of the most recent prescriptions were not being kept with the medication administration charts. The manager had obtained a controlled drug register since the last inspection from the pharmacist. This was not appropriate for use in a residential home as it was for use by a pharmacist. An appropriate version needed to be purchased. Residents, rights to privacy and dignity were generally 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. Staff were observed on two occasions entering people’s bedrooms without knocking the door and must be reminded to do this on all occasions. Abbey Park DS0000017004.V334568.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. This judgement has been made using available evidence including a visit to this service. There are no rigid rules or routines in the home and there are activities available for people to take part in if they wished. The arrangements for visiting the home enabled visitors to come at any reasonable hour. The catering arrangements at the home met the needs of the people there. EVIDENCE: The atmosphere in the home throughout the course of the inspection was very relaxed. All the people living at the home that were seen or spoken with were very content. There were no rigid rules or routines in the home and the people living there spoke to the inspectors about getting up and going to bed when they wished and going to the local shops on a daily basis for a newspaper. The people living at the home had the choice of three sitting areas one of which was a designated smoking area. One of the men living at the home was still having his breakfast when the inspectors toured the home as he liked to have a lie in and commented ‘they are taking pretty good care of me’. Holy Communion was held in the home on the day of the inspection for those people wishing to take part. Another person living there informed the inspectors she went to church every Sunday. Abbey Park DS0000017004.V334568.R01.S.doc Version 5.2 Page 15 There were activity records for each person living at the home. Activities recorded included watching television, having manicures, visitors, watching a film, chair aerobics, watching the Grand National, reminiscence, games with sponge ball, reading the newspaper and interacting with others. The activities offered by the home did vary from person to person. The manager commented that it was difficult to motivate some of the people living in the home and that they had tried to discuss activities with them. It was recommended that staff recorded when anyone refuses an activity and if anything else was offered to evidence the full range of what was offered. 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 the people living there went out with their relatives if they wished. One person at the home commented that she went out with her niece. It appeared that the people living in the home 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. One of the people living at the home spoke of being asked if he would like to vote in the forthcoming election and had received his voting papers. People had been encouraged to personalise their rooms to their choosing and personal effects were seen in all the bedrooms sampled during the course of the inspection. All the people living at the home who were spoken to on the day of the inspection were very happy with the meals being served. The inspectors had lunch on the day of the inspection. The meal was well cooked and nicely presented. It was evident that staff knew what the people who lived there liked and meals varied accordingly. Some had chips, others mashed potatoes, some had garden peas others mushy peas, people were asked their preferences in relation to their sweet and the drink accompanying their meal. One person was seen to have sandwiches, which they stated was their choice as they were not keen on cooked meals. They also said they had something cooked at teatime and bacon sandwiches for breakfast. The food records showed that there was a good variety of nutritious food served to the people living there. Abbey Park DS0000017004.V334568.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is an appropriate complaints procedure for the home and the people living there were listened to. People living at the home are safe guarded by the policies and procedures at the home and the training staff had received. EVIDENCE: The home had not received any complaints since the last inspection and none had been lodged with the CSCI. The complaints procedure has been seen at previous inspections therefore was not viewed at this visit. All the people living at the home had received a copy of the complaints procedure in the service user guide. The people living at the home were very comfortable in the presence of the staff and the manager which would give them the confidence to raise any issues they may have. There had been no adult protection issues raised at the home since the last inspection. There were policies and procedures on site for adult protection and the manager had obtained a copy of the multi agency guidelines for adult protection. Part of the home’s procedure 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. This remains outstanding from the last inspection. Staff had received training in adult protection issues. For some it was recommended this be updated so Abbey Park DS0000017004.V334568.R01.S.doc Version 5.2 Page 17 that they were aware of the most recent procedures for reporting any suspicions or allegations of abuse. A member of staff who was asked about adult protection was very clear that if there were any issues while she was on duty she would report them straight away. Abbey Park DS0000017004.V334568.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is generally well maintained and safe and provides the people living there with a comfortable and homely environment in which to live. EVIDENCE: At the time of the random inspection in November 2006 the majority of the requirements made at the key inspection had been met. Improvements included, new flooring in the corridor outside the kitchen, an emergency call point was visible in the dining room, the dining room window had been secured, the uneven paving in the garden had been addressed, the self closure on the kitchen door had been repaired and the fire doors had been repaired as required. Redecoration was ongoing in the home and bedrooms were decorated as they became vacant. Abbey Park DS0000017004.V334568.R01.S.doc Version 5.2 Page 19 There had been no changes to the layout of the home since the last inspection. The home was found to be generally comfortable and the people living there appeared happy with the environment. 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 of the people living at the home chose to eat in the lounges and there was also a table in the smoking room if people preferred to eat in there. The communal areas were adequately furnished and decorated. 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 were a variety of aids and adaptations throughout the home including, ramped entrance, shaft and stair lift, hoist, and emergency call system. There were some hand and grab rails but in some corridors there were no handrails and in others they were only to one side. This had been discussed at previous inspections and the proprietor had assessed whether he would be able to fit additional handrails but the corridors were thought to be too narrow for this. Bedrooms in the home were a mix of singles and doubles, varied in size and some had en-suite facilities. The bedrooms of the people being case tracked were seen during the inspection. Not all the required furnishings were available in all the rooms, for example, two chairs. The manager needed to audit all the rooms against the National Minimum Standards and discuss with the people living there their requirements. Where they 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 noted that in one bedroom the occupant had removed the window restrictor. As the individual could be at risk from this a stronger window restrictor needed to be fitted. The home was clean and odour free on the day of the inspection. The laundry was appropriately located and had a sluice machine installed. There was no wash hand basin in the laundry but there was one in the staff toilet next door. The kitchen was very clean and tidy and judging from the comments made by the environmental health officer on a recent visit this is ongoing. The report stated ‘excellent quality management system and HACAP in place, excellent standards of food hygiene’. Abbey Park DS0000017004.V334568.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Adequate staffing levels are maintained to enable the needs of the people living at the home to be met. Arrangements for staff induction training had improved and ensured staff were able to deliver adequate and appropriate care. Recruitment procedures are robust and protected the people living in the home. 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 people living there. The home was fully staffed at the time of the inspection. Staffing levels were good with four staff on duty during the morning shift and three during the afternoon and evening. Two waking night staff were on duty each night. Also employed at the home were catering and domestic staff. The interactions between the staff and the people living at the home were observed throughout the day and were very good. People living at the home were very comfortable in the presence of the staff and the manager and friendly relationships were evident. The recruitment and training files were sampled for three new staff. All the required documentation had been obtained prior to the staff commencing work at the home. Abbey Park DS0000017004.V334568.R01.S.doc Version 5.2 Page 21 There was an initial induction checklist for the new employees which covered all the basic areas of the work role. They then went on to complete a full induction in line with the specifications laid down by skills for care. There had been an organisational training needs analysis undertaken by an outside training organisation in March 2007 to identify the training needed by staff. The manager had developed a training matrix for the home which detailed that the majority of the staff had received most of their mandatory training, for example, first aid, infection control and health and safety. Some of the training was in need of updating for some staff, for example, food hygiene and fire training. Fire training was taking place only once a year facilitated by an outside organisation. This needs to take place twice yearly it was suggested that one session of this could be done by the manager with the aid of a video. Staff had just undertaken moving and handling training and had also had challenging behaviour training. It was recommended that the training matrix was developed further to include topics other than mandatory training to give a true reflection of all training. Of the 19 care staff employed at the home seven had NVQ level 2 and another 3 were undertaking the training which would give the home the required 50 . Abbey Park DS0000017004.V334568.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 37 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager ensures 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 people that live there with a view to continuous improvement. EVIDENCE: Throughout the inspection the manager of the home demonstrated her ability to care for the people living at the home and run a residential home. Since she has been in post numerous improvements have been made at the home. She had a very good knowledge of the needs of the people living at the home and Abbey Park DS0000017004.V334568.R01.S.doc Version 5.2 Page 23 demonstrated a commitment to improving the service as much as possible. She had a very good relationship with the proprietor and stated he was very supportive and a regular visitor to the home. Since the last inspection the home has had a variation to their registration to enable them to care for six people with dementia. At the time of this visit three new people with dementia had been admitted and the home were managing this well. The manager was very complimentary about her staff team and stated they work well together and were very aware of their responsibilities. Good relationships within the staff team were evident. The home was run with an open and inclusive atmosphere and there was a very friendly and relaxed atmosphere. As at the last inspection 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. The manager needed to ensure there was a formalised quality monitoring system in place at the home based on seeking the views of the people who live in the home. The outcome of the quality system should be a yearly development plan for the home with the aim of continually improving the service. The manager was handling the personal allowance for some of the people living there. A specific account had been set up by the proprietor for some 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 these people had individual books where this was recorded. One of these was sampled. 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 individuals. Other people living in the home also had some personal allowance managed by the home which was deposited with the manager by their relatives. These people also had individual books that detailed all income and expenditure two of these were also sampled. It was noted that for one person one receipt was missing for a purchase made on her behalf. 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 an ongoing requirement that these visits take 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 at the home were well managed. The issues raised at the random inspection: the fire alarm service, remedial works on the lift and prevention of legionella checks had been addressed. Staff had received training in safe working procedures. There was evidence on site that the equipment Abbey Park DS0000017004.V334568.R01.S.doc Version 5.2 Page 24 was serviced regularly and all the in house checks on the fire system were up to date. It was noted that there were no records of a recent fire drill which need to take place every six months. Accident and incident recording and reporting to the Commission were appropriate. Abbey Park DS0000017004.V334568.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 3 3 2 X 2 X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 2 X 2 2 Abbey Park DS0000017004.V334568.R01.S.doc Version 5.2 Page 26 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 OP3 Regulation 14(1) Requirement The manager must ensure she obtains a copy of the social work assessment prior to the admission of any people to the home. This will ensure that staff know the needs of people wanting to live in the home. (Previous time scales of 01/07/06 and 01/12/06 not met.) 2. OP7 15(1) All people living in the home 01/06/07 must have care plans that clearly detail how all their needs in respect of health and welfare are to be met by staff. Care plans must include individual abilities, likes, and dislikes, preferences and their preferred daily routines and be regularly reviewed. This will ensure that people living in the home receive individual care that meets their needs. (Previous time scale of 01/08/06 and 01/01/07 partially met.) Abbey Park DS0000017004.V334568.R01.S.doc Version 5.2 Page 27 Timescale for action 31/05/07 3. OP7 13(5) 4. OP7 13(4) 5. OP9 13(2) People living in the home must have manual handling risk assessments that detail how they are to be assisted in the event of a fall. These must detail any equipment to be used. This will ensure the safety of the people living in the home. (Previous time scales of 01/07/06 and 14/12/06 not met.) All people living in the home must have personal risk assessments that detail how any identified risks are to be minimised by staff. This will ensure the safety of the people living in the home. Regular staff drug audits must be undertaken before and after drug rounds to ensure staff competence when administering medication. This will ensure people receive the correct levels of medication. An appropriate controlled drugs register must be purchased. This will ensure appropriate monitoring of any controlled medication being administered. 01/06/07 31/05/07 31/05/07 6. OP18 13(6) The adult protection procedures 31/05/07 in the home must be amended to ensure they comply with the multi agency guidelines. This will ensure people living at the home are safeguarded. (Previous time scale of 01/07/06 and 01/12/06 not met.) The window restrictor identified during the inspection must be replaced. This will ensure the occupant of the room is safe. 50 of care staff must be DS0000017004.V334568.R01.S.doc 7. OP24 13(4) 14/05/07 8. OP28 18(1)(a) 01/09/07 Version 5.2 Page 28 Abbey Park 9. OP30 18(1)(a) 10. OP33 24(1) qualified to NVQ level 2 or the equivalent. This will ensure staff have the necessary skills and knowledge to care for the residents. The registered person must 01/07/07 ensure that all staff have completed the appropriate training in safe working practices to include: Food hygiene Fire safety This will ensure the safety of the people living at the home. The home must have a system in 01/07/07 place for monitoring the quality of the service offered based on seeking the views of the residents with a view to continuous improvement. This will ensure the service offered in the home is kept to an acceptable standard for the people living there (Previous time scales of 31/08/06 and 01/12/06 not met.) The registered person must ensure that receipts are obtained for any expenditure made on behalf of people living at the home. This will ensure people living at the home are safe guarded. The responsible individual for the home must visit the home unannounced at least monthly and prepare a report about the conduct of the home. These reports must be made available for inspection. This will ensure people living in the home know someone is overseeing the management of the home. (Previous time scales of 01/07/06 and 01/12/06 not met.) 11. OP35 17(2) schedule 4(9) 21/05/07 12. OP37 26 01/06/07 Abbey Park DS0000017004.V334568.R01.S.doc Version 5.2 Page 29 13. OP38 23(4)(e) There must be evidence on site that fire drills are undertaken every six months. This will ensure the safety of the people living in the home. 31/05/07 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. 4. Refer to Standard OP10 OP12 OP18 OP24 Good Practice Recommendations To ensure that the privacy of the people living in the home is not compromised staff must remember to knock bedroom doors before entering and wait for a response. Recording of activities should be reviewed so that it can be evidenced when people living in the home have refused an activity and if an alternative was offered. To ensure the people living in the home are fully safeguarded staff should have their adult protection training updated. Not all the bedrooms had all the furniture and fittings detailed in the National Minimum Standards. This should be discussed with the residents to ensure the furnishings meet with their needs. It was recommended that the training matrix was developed further to include topics other than mandatory training to give a true reflection of all training staff had undertaken. 5. OP30 Abbey Park DS0000017004.V334568.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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. Extracts may not be used or reproduced without the express permission of CSCI Abbey Park DS0000017004.V334568.R01.S.doc Version 5.2 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. 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