Inspection on 14/08/06 for Abbey Place Care Home Trading As Southern Cross Healthcare

This inspection was carried out on 14th August 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Abbey Place Care Home Trading As... 08/06/09

Abbey Place Care Home Trading As... 12/06/07

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Tyndale Avenue

2-10 Norfolk Road

Bennfield House Nursing Home

Eastfield Residential Home

Sign Health

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

CARE HOMES FOR OLDER PEOPLE Abbey Place Care Home t/a Southern Cross Healthcare 90 Abbey Road Fartown Huddersfield West Yorkshire HD2 1BB Lead Inspector Stephen French Unannounced Inspection 09:30 14 August 2006 th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Abbey Place Care Home t/a Southern Cross Healthcare DS0000065974.V301721.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 Place Care Home t/a Southern Cross Healthcare DS0000065974.V301721.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbey Place Care Home t/a Southern Cross Healthcare 90 Abbey Road Fartown Huddersfield West Yorkshire HD2 1BB 01484 469946 01484 423399 Address 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) www.southerncrosshealthcare.co.uk Ashbourne (Eton) Limited Mr Alan Firth Care Home 78 Category(ies) of Dementia - over 65 years of age (78), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (10) Abbey Place Care Home t/a Southern Cross Healthcare DS0000065974.V301721.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. House 3 to accommodate one named person (MD category) under 60 years of age. House 1 and 2 to accommodate 38 DE(E) personal care only House 3 and 4 to accommodate 40 DE(E), 10 MD(E) Date of last inspection 28/02/06 Brief Description of the Service: Abbey place provides accommodation for up to seventy-eight older people in a purpose built nursing home located in the Fartown area of Huddersfield, approximately one mile from the town centre. The home comprises of three separate units for service users, an administration area and a basement containing the kitchen, laundry and storage areas. The home has a separate activities/hairdressing area. House 1and 2 provides accommodation and personal care for older people with dementia. House 3 provides accommodation and nursing care for twenty older people with dementia and up to ten older people who have a history of mental illness. House 4 provides accommodation and nursing care for twenty older people with dementia. There are ample parking spaces and there are well-maintained gardens around the houses. The provider informed the Commission for Social Care Inspection on 5/07/06 that fees range from £341.46 to £535.68 per week. Additional charges include hairdressing, private chiropody, newspapers, toiletries and some selected activities. Information about the home and the services provided are available from the home in the statement of purpose and service user’s guide. Service users can access these and Inspection reports from the home. Abbey Place Care Home t/a Southern Cross Healthcare DS0000065974.V301721.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report refers to a key inspection, which included an unannounced visit to the home on the 14th August 2006. The inspector arrived at the home at 9:05 am and left 3:30pm. During this visit the inspector spoke to some of the service users, some of the staff and the home’s management as well as a relative. The inspector read care records, audited a sample of medication, reviewed staff recruitment and training records and carried out a brief tour of the building. Prior to the inspection 20 relative questionnaires were sent out to obtain their users’ views about the care at the home. Twelve completed questionnaires were returned. Some service users in the home are very frail and would not be able to complete a questionnaire. Positive comments received from relatives included “The staff are very caring and work hard”, “Everyone is very caring”, “Carers, cleaners and maintenance staff seem to have very caring attitudes” “consultation and openness is good”. Negative comments included, “I do not feel that there are enough staff on duty to care for the residents” “I often have to go and search for staff” “I don’t feel the residents continent needs are attended to as often as they should” Comment cards were also received from a GP and a District Nurse. There were seventy-eight service users resident in the home on the day of this visit. Other information used in the inspection process included notifications from the provider to the Commission for Social Care Inspection about deaths, illnesses, accidents and incidents at the home, copies of the monthly management visit reports produced by the provider and a pre inspection questionnaire completed by the manager. Although there has been a marked improvement in the home, there are still issues relating to the health and safety of service users identified in the body of this report Abbey Place Care Home t/a Southern Cross Healthcare DS0000065974.V301721.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Provide a terms and conditions of admission document (contract) to those service users who fund their own care. Improve the standard of care planning to ensure they reflect the current and changing health and personal needs of the service users. Ensure staff follow the homes policies and procedures on the ordering, storage and administration of medication. Provide dedicated social activities for service users who have mental health problems. Ensure there are adequate numbers of staff on duty, especially at peak times, to enable the needs of the service users to be met. Provide a system that ensures service users have access to their personal monies especially out of office hours. Staff should receive at least six formal supervisory sessions per year. Parts of the home should be redecorated Please contact the provider for advice of actions taken in response to this Abbey Place Care Home t/a Southern Cross Healthcare DS0000065974.V301721.R01.S.doc Version 5.2 Page 7 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Abbey Place Care Home t/a Southern Cross Healthcare DS0000065974.V301721.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 Place Care Home t/a Southern Cross Healthcare DS0000065974.V301721.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2&3 Service users needs are assessed prior to their admission to ensure that the home and its staff can meet those needs. Service users do not receive a terms and conditions of admission document which informs them of what the fees do and do not include and if there are any extra charges. Quality in the outcome area is Adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Service users moving into the home, and whom the local authority fund, have a written contract signed by the placing authority. This informs them of the contribution they are required to pay towards their care. Due to the home having recently changed hands, new service users are not given a terms and conditions of admission document by the home This document informs the service user what the fees do and do not include and if there are any additional charges. The manager stated that these contracts were being reviewed to include the name of the registered providers and would be issued to all service users. A concern raised by a relative highlighted that Abbey Place Care Home t/a Southern Cross Healthcare DS0000065974.V301721.R01.S.doc Version 5.2 Page 10 the service users are responsible for purchasing their own toiletries, however it did not state this in the terms and conditions document seen by the inspector. The manager stated that he or his deputy visits each prospective service user prior to them being admitted to the home. The purpose of the visit is to complete a pre-admission assessment to ensure the home is able to meet the needs of the service user. The assessment consists of a scoring system, which is based on twelve activities of daily living, such as eating and drinking, hygiene, elimination and communication. Each activity is scored and the service users dependency level is determined. Following the assessment the service user is informed by letter of the date of their admission and which room they are to occupy. Completed pre-admission assessments were seen for three recently admitted service users Abbey Place Care Home t/a Southern Cross Healthcare DS0000065974.V301721.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 Health and personal care practices are inadequate which may result in poor or inconsistent care being received by service users. Medication practices and processes are unsafe. Quality in the outcome area is Poor. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Each service user has an individual support plan, which has been developed from information gathered from the community care assessment and members of the multidisciplinary team. As part of the inspection six-service users care files were examined. There has been an improvement in the content of these plans since the last inspection and there is detailed information on what personal and health care support the service users require. There are assessments for moving and handling, nutrition and skin integrity however, a number of these have not been reviewed monthly. A moving and handling assessment had been completed on the 8/8/06 but the service user had been admitted in July. One care plan, which identified a service user as displaying inappropriate sexual behaviour, had not been reviewed since May Abbey Place Care Home t/a Southern Cross Healthcare DS0000065974.V301721.R01.S.doc Version 5.2 Page 12 2006 and a risk assessment had not been put into place. Although a number of care plans and assessments examined had been reviewed monthly, a number had not. This needs to be addressed to ensure that the current health care needs of the service users are being met. There was evidence in the files examined that staff access other members of the multidisciplinary team such as district nurses, chiropodists and members of the mental health team. Comment cards received by the Commission for Social Care Inspection from visiting health professionals stated that at times it was difficult to identify which house service users are located in, and requests for visits from staff to GP’s is often uncoordinated leading to frequent visits by a GP. Another comment card stated that staff do not always demonstrate a clear understanding of the service users care needs. Another comment card stated that it was often difficult to find staff when visiting, and specialist advice given to staff by other health professionals is not always incorporated into the service users care plan. Senior care staff are responsible for the administration of medication in the residential unit. Qualified nursing staff administers medication in house 3 and 4. During the inspection a selection of service users medication was examined in all three houses. Following the administration of medication staff sign the medication sheet to confirm that the medication has been given. If a service users refuses medication or it is omitted for any reason then a code is recorded to inform staff of the reason for this. It was noted that on the residential unit there were a number of signature omissions on the medication administration record but the medication had been removed from the blister pack indicating that it had been given. It was also noted that one medication had been signed as given but was still in the pack. During a tour of the residential unit it was also noted that the medication trolley was located in the downstairs corridor and it was not locked to the wall. These practices could place the service user at risk and staff must ensure that they follow the homes policies and procedures on the administration of medication. Abbey Place Care Home t/a Southern Cross Healthcare DS0000065974.V301721.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15 Service users’ social, cultural, religious and recreational needs are not being met. Family and friends are able to visit the home at any time of the day and early evening. Staff assist the service users in exercising choice in most things they do. Meals are varied and nutritious. Quality in the outcome area is Adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Since the last inspection the activities co coordinator has left and the home is currently trying to replace her. At the moment it is the responsibility of the care staff to organise and supervise any social activity taking place, the manager said that extra staff were on duty to cover this. On the day of the inspection the inspector did not observe any social activity taking place, however staff were seen sitting in the lounge areas chatting to service users. Two comment cards received from relatives mentioned the lack of social activities on offer. The manager said that service users are able to receive visitors at any time of the day and early evening. Visits from family and friends can take place in either the service users room or one of the communal lounges. On the day of Abbey Place Care Home t/a Southern Cross Healthcare DS0000065974.V301721.R01.S.doc Version 5.2 Page 14 the inspection visitors were seen entering the home at different times during the day. Within the care files inspected there was evidence that those service users who are able to, are encouraged to exercise choice in most things they do. This includes the time they rise and retire and where they spend their day. Service users who lack capacity are assisted and guided to make choices by care staff. The home operates a four-week menu, which consists of the choice of two main dishes. The main meal is served at teatime and there is a snack lunch. On the day of the inspection the lunch consisted of beans and sausages or sandwiches. Previously the home used a catering company who provided the kitchen staff and food. Since the home has changed ownership the kitchen staff are now employed by the home and are responsible for purchasing food and preparing the menus. Due to the varying degree of the mental health problems of the service users it was not possible to seek their views on the food that is provided, although those service users spoken to said the food was nice. Abbey Place Care Home t/a Southern Cross Healthcare DS0000065974.V301721.R01.S.doc Version 5.2 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 home has a comprehensive complaints policy, and service users and relatives are confident appropriate action will be taken to address any issues. Staff receive training in the protection of vulnerable adults, which helps to protect the service users from harm. Quality in the outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The home has a complaints policy, which was displayed in the main reception of the home. The manager said that each service user is given a copy of the policy on admission. Eight relative comment cards received confirmed that they were aware of the homes complaints policy and that they would be confident that the manager would address these appropriately. Since the last inspection the Commission for Social Care Inspection has received two concerns, one from a relative who was concerned about the room their relative was allocated and another from the Contracts manager of Calderdale council surrounding the care a service user had received whilst on respite at the home. Evidence was seen that the home had investigated these complaints adequately and had actioned any shortfalls. The home has policies and procedures in place to protect the service users from abuse. Staff receive training in the protection of vulnerable adults as part of their induction training as well as an annual update. Evidence was seen that all staff had completed adult protection training. Staff receive a copy of the whistle blowing policy, which outlines their responsibilities in reporting any Abbey Place Care Home t/a Southern Cross Healthcare DS0000065974.V301721.R01.S.doc Version 5.2 Page 16 concerns they have. Four staff spoken to gave good responses to questions asked by the inspector on this subject. Abbey Place Care Home t/a Southern Cross Healthcare DS0000065974.V301721.R01.S.doc Version 5.2 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 & 26 Service users lifestyles could be further enhanced if the home was decorated to reflect the needs of service users suffering from dementia. Although the home appeared clean there were odours detected in the residential unit and house 3. Quality in the outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: As part of the inspection a tour of the home was conducted which included communal areas, bathrooms and a number of service users bedrooms. Residential unit Since the last inspection new garden furniture has been purchased and the lounge has been re-carpeted. The corridor and dining room on the ground floor are in need of redecoration as these are looking very worn and tired. The flooring in the drugs room is in need of replacing and a curtain pole in the upstairs lounge had fallen off and should be replaced. There was an odour of Abbey Place Care Home t/a Southern Cross Healthcare DS0000065974.V301721.R01.S.doc Version 5.2 Page 18 urine detected on both floors. Comment cards received from relatives all mentioned the smell of urine within the home. The manager stated that they had replaced carpets and had a cleaning program in place. House 3 Again there needs to be some redecoration of the upstairs lounge and replacement of carpets. There was a odour of urine along one corridor and also in the upstairs lounge. House 4 Since the last inspection this unit has undergone some redecorated and corridors have been themed. Bedroom doors have been fitted with letterboxes and doorknockers to resemble a front door and street lamps have been placed along some of the corridors whilst walls have imitation brickwork, which gives the feeling that you are walking along a street. This has been done to enable those service users with dementia to feel more as though they are in their own home and orientated to their room. The manager stated that there were plans to continue with the redecoration when more funds were available. Following a recommendation made during the last inspection appropriate seating has been provided for service users who have mobility problems. Abbey Place Care Home t/a Southern Cross Healthcare DS0000065974.V301721.R01.S.doc Version 5.2 Page 19 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): 27,29 & 30 There does not appear to be adequate numbers of staff on duty to be able to care for the psychological, physical and social wellbeing of the service users living in the residential unit. The homes recruitment procedures are robust and protect the service users from harm. Staff receive adequate training in order for them to be able to care for the service users. Quality in the outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Senior care staff and care staff staff the residential unit. House 3 and 4, which are the nursing units are staffed with qualified nursing staff that are supported by care staff. Staff holidays and sickness are covered by bank staff, or staff doing overtime. There has been twenty-four hours of agency staff used over the last eight weeks and twenty-eight staff have left since the last inspection. The staff duty rota was checked for the month of July and the staffing numbers consisted of: Residential unit AM; six or seven care staff, PM; six care staff, and at night there are three care staff. House 3, AM; one qualified nurse and three care staff, PM; one qualified nurse and three care staff. Abbey Place Care Home t/a Southern Cross Healthcare DS0000065974.V301721.R01.S.doc Version 5.2 Page 20 House 4, One qualified nurse and three care staff AM and PM. Comment cards received from relatives all stated that there were not enough staff around to care for their relatives and this was particularly directed at the residential unit. The manager stated that since July 2006 the numbers of staff have increased to six as he had identified a need for more staff. However the inspector was informed that the staffing numbers had been increased due to there being no activities advisor and to allow staff to arrange and supervise activities. Once an activities advisor is employed the numbers of care staff would be reduced. The manager is responsible for the recruitment and selection of staff. The records for five staff recently employed by the home were examined. These contained application forms, interview assessments, references and confirmation that checks with the criminal records bureau had been undertaken. New staff receive a one day induction program prior to them commencing employment. During this day staff receive training in moving and handling, fire awareness, the philosophy of care of the home as well as abuse training. Following the one-day training staff complete induction training, which consists of completing five units of training, which includes, amongst other things, the needs of the service users and the role and responsibilities of staff. Abbey Place Care Home t/a Southern Cross Healthcare DS0000065974.V301721.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 & 38 The home is managed by a competent manager, who is aware of the aims and objectives of the home. Service users financial interests are safeguarded by the homes policies and procedures. Quality in the outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The manager of the home Mr Alan Firth is a qualified nurse who has had many years of experience in working with older people, and a Deputy manager. supports him in his role. There is an expectation that all managers of a care home complete a recognised management course such as the registered managers award. The manager stated that he had completed six units of the course during his previous employment but has not recommenced this. Abbey Place Care Home t/a Southern Cross Healthcare DS0000065974.V301721.R01.S.doc Version 5.2 Page 22 The manager completes monthly audits of the home and the services they offer the last audit conducted in July 2006 scored 80.31 . Areas audited included, presentation of the home and exterior grounds, enquiries made by new service users, medication, care documentation, complaints and accidents finance and maintenance. The deputy manager also completes monthly statistics and is responsible for ensuring staff receive the training they require in order for them to be competent at the job they are performing. Evidence was seen that 60 of staff have received training in moving and handling, 68 of the staff have had training in fire prevention and 12 of staff have health and safety training. It is expected that all staff receive at least six formal supervisory sessions per year during these sessions staff discuss future training needs as well as the philosophy and aims and objectives of the home. 68 of staff have received regular supervision. The manager stated that the qualified nursing staff had originally been responsible for supervision of care staff but this had not taken place, therefore the deputy manager is to take over this role. Service users personal monies are kept in a central account held by the providers, this is a non-interest account and individual records of all transactions are kept for each service user. Should a service user wish to purchase small items of clothing or pay for hairdressing then this is taken out of the account and a receipt is issued. A copy of transactions undertaken is sent to the service users relative monthly. Three amounts of service users monies were checked and the balances tallied with records held. The manager and the administrator are the only staff who have access to the service users monies held within the home. If a service user wished to withdraw any money after office hours or at weekends then they would have to give notice so that their money could be made available. The manager stated that the providers were looking at a system whereby service users could access money at anytime. Staff have received training in moving and handling, first aid and fire prevention, records checked confirmed this. The fire alarm system is checked weekly and certification in relation to gas, electricity and water is in place and up to date. Electrical equipment such as hoists and the passenger lifts are serviced regularly. Abbey Place Care Home t/a Southern Cross Healthcare DS0000065974.V301721.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 2 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 2 X 3 Abbey Place Care Home t/a Southern Cross Healthcare DS0000065974.V301721.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 (1) Requirement Service users care plans must reflect the current needs of the service user and should be reviewed at regular intervals. Previous Requirement 30/9/05 & 28/2/06 Stock balances of medication must be recorded. Previous requirement 30/9/05 and 28/02/06 Staff must follow the homes administration of medication policy. Make arrangements for service users to engage in social and community activities The registered person should keep the home reasonable decorated. Previous requirement 28/2/06 Keep the home free from offensive odours Previous requirement 28/2/06 The registered provider must ensure that there are adequate DS0000065974.V301721.R01.S.doc Timescale for action 30/11/06 2. OP9 13 (2) 30/11/06 3 4. OP12 OP19 16 (2) M 23 (2) d 30/11/06 30/11/06 5. OP26 16 (2)k 30/11/06 6. OP27 18 (1) a 30/11/06 Abbey Place Care Home t/a Southern Cross Healthcare Version 5.2 Page 25 7. OP36 18 (2) numbers of staff on duty to care for the service users needs Staff must receive regular supervisory practice 30/11/06 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 Refer to Standard OP2 Good Practice Recommendations The home should produce a terms and conditions document outlining what the fees do and do not include and this should be signed by the service user or their representative. Risk assessments should be completed fully and reviewed at regular intervals. The areas identified during the inspection as requiring redecoration and new carpets should be actioned. The curtain pole should be replaced. 4. 5. 6. OP31 OP35 OP9 The flooring in the drugs room should be replaced. The manager should recommence the registered managers award. Service users should be able to access their personal moneys out of office hours and at weekends if they wish. The medication trolley should be secured to the wall when being left on the ground floor 2. 3. OP7 OP19 Abbey Place Care Home t/a Southern Cross Healthcare DS0000065974.V301721.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB 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 Place Care Home t/a Southern Cross Healthcare DS0000065974.V301721.R01.S.doc Version 5.2 Page 27 - 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. 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