CARE HOMES FOR OLDER PEOPLE
Abbey Road [53] 53 Abbey Road Newbury Park Ilford Essex IG2 7LZ Lead Inspector
Julie Legg Key Unannounced Inspection 10:00 22nd February – 8th March 2007 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 DS0000025946.V331321.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. DS0000025946.V331321.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Abbey Road [53] Address 53 Abbey Road Newbury Park Ilford Essex IG2 7LZ 0208 518 6757 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) Servite Houses Limited Nova Ann O`Sullivan Mrs Nova O`Sullivan Care Home 18 Category(ies) of Dementia - over 65 years of age (18), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (18) DS0000025946.V331321.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 2nd November 2005 Brief Description of the Service: 53 Abbey Road is an 18-place care home with nursing for older people, who have dementia or mental health issues. The home is operated by Servite Houses Ltd, a national charity that provides similar homes across England. The home has a contract with the local Primary Care Trust; therefore the home only accepts referrals from the Trust. The home is purpose built and is situated in a residential area of Newbury Park, close to tube and bus routes. The accommodation is spread over two floors, with nine single, en-suite, bedrooms, bathrooms and toilets on each floor. There is a passenger lift and all parts of the building have full disabled access. There is a lounge/dining area on each floor, with an additional lounge on the ground floor, through which a well maintained garden is accessed. Nursing and personal care are provided on a 24-hour basis and specialist health needs are met by visiting professionals. The Statement of Purpose and the Service User Guide are issued to every prospective resident and both of these documents are displayed in the entrance hall of the home. A copy of the most recent inspection report is also available. A resident or relative/representative could ask for his or her own copy, which the manager would make available. All of the beds within Abbey Road are blocked purchased by the local Primary Care Trust. DS0000025946.V331321.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced key inspection took place over two days. The inspector spoke to residents about their experience of moving into and living at the home and to six relatives, three who were visiting the home at the time of the inspection and three by telephone. The inspector also spoke to a GP who was also visiting the home at the time of the inspection. Discussions took place with the manager; two nurses, the chef and four care staff. Staff were spoken to about care practices and their employment at the home. They were observed directly and indirectly providing care to residents. A tour of the home was undertaken and a number of resident and staff files as well as other records were examined. What the service does well: What has improved since the last inspection?
DS0000025946.V331321.R01.S.doc Version 5.2 Page 6 The home had one previous requirement, which has been met. The manager ensures that all fire doors are not wedged open. What they could do better: 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. DS0000025946.V331321.R01.S.doc Version 5.2 Page 7 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 DS0000025946.V331321.R01.S.doc Version 5.2 Page 8 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): 1,3,4 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and their relatives have detailed information on the home, which assists them to make an informed choice about moving into the home. A detailed pre-admission assessment is undertaken of all prospective residents, this will ensure that their identified needs can be appropriately met by the home. Prospective residents and their relatives are able to visit the home prior to their admission. EVIDENCE: The Statement of Purpose clearly sets out the objectives and philosophy of the service and clearly states what the home can provide. The Service User guide is informative and written in plain English, a copy of this document has been given to all of the residents.
DS0000025946.V331321.R01.S.doc Version 5.2 Page 9 The files of three residents were looked at. The manager had undertaken an in-depth assessment, which included sections on; personal care, covering areas such as ability to wash, step into a bath and putting on shoes. Other sections covered: communication, mobility, personal safety, risks and medical history including physical and mental health. Other areas covered in the assessment included; diet, weight, dental and foot care and social activities. Further information was also obtained from health professionals and family, prior to the resident’s admission to the home. Residents and relatives are able to visit the home prior to a resident moving in. The inspector spoke to six relatives, all of whom stated their parents or partners were unable to visit the home prior to their admission due to their frailty. However all of the relatives had visited the home prior to their relative’s admission. One relative stated, “they made me feel very welcome, nothing was too much trouble”. Another relative stated, “when I walked in I could hear residents and staff chatting and laughing and Nova (manager) had been to see my relative and knew such a lot about them”. The home does not provide intermediate care. DS0000025946.V331321.R01.S.doc Version 5.2 Page 10 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care needs of each resident are set out in individual care plans. These comprehensive plans provide staff with detailed information, which ensures that care needs are being met on a daily basis. There are clear medication policies and procedures for staff to follow and medication records are being completed correctly, this safeguards the residents with regard to the administration of their medication. Residents are treated with respect and the arrangements for their personal care ensures that their right to privacy is upheld. EVIDENCE: DS0000025946.V331321.R01.S.doc Version 5.2 Page 11 Each resident has their own care plan; the inspector examined four of these plans. Each resident’s care plans is broken down into morning, afternoon, evening and night care. The care plans are very detailed, comprehensive and person- centred, identifying the resident’s personal, social, health, cultural and religious needs, as well as likes and dislikes, happy and painful memories, strengths and limitations and how these needs and wishes should be met. They also identify essential things or routines that are important to the resident. As stated earlier the care plans are person-centred and had details such as ‘X will inform staff when she wishes to have a bath’. ‘Y likes early morning (6.00) coffee in the lounge’. ‘Z will be given the menu so that she can choose her meals’. Daily records indicated that care plans were being followed and recordings related to the care plans; ‘Just after midnight Y had her breakfast in the lounge; she was assisted to write a letter and then went back to bed. She got up at 6.50 and had her coffee in the lounge’. There was evidence that residents’ care plans are being evaluated on a regular basis or when a change in need is identified. One resident’s care plan was updated on 13/2/07 due to a deteriation in his physical health; areas covered were nutritional intake, skin pressure care and management of medication. From the evidence gathered it is obvious that the manager and staff have worked hard into this aspect of residents’ lives and a score of 4 (commendable) has been given in recognition of this. There was evidence that body maps are being completed following an accident or incident. The recordings of fluid and food intake and pressure wound charts were all completed satisfactorily. The tissue viability nurse has been involved with some of the residents and she is satisfied with the actions of the staff. All residents are weighed regularly and if any weight loss is noted over two consecutive weighings then the resident is referred to their GP or dietician. Residents’ files also have written evidence that they are seen by other health professionals including opticians, dentists, chiropodists, tissue viability nurse, GP and hospital out-patient appointments. Some of the residents are taken to health appointments and other residents receive their health care within the home. The inspector was able to speak to the GP who was visiting the home at the time of the inspection, he stated, “It is a very nice home, the staff are very considerate to the residents. The staff are very pro-active in relation to residents’ health and will always ring if they have any concerns”. Risk assessments were examined, those seen were detailed and covered areas such as, personal safety/protection, diet/fluid intake, skin pressure area care, nutritional intake, use of hoist and wheelchairs. Residents where possible, relatives and health professionals have been consulted in the formulating of these risk assessments. There was evidence that risk assessments are being reviewed and regularly updated.
DS0000025946.V331321.R01.S.doc Version 5.2 Page 12 Medication policies and procedures were examined and found to be up to date. Only nursing staff can administer medication. Four residents’ Medication Administration charts were examined and all had been completed appropriately and medication given correlated with the MAR charts. Regular management checks are recorded to monitor compliance. The inspector spoke to a number of residents and relatives who all said that staff were very respectful and thoughtful when attending to personal care. One relative stated, “they are exceptionally kind and treat my wife with respect and dignity, I can’t fault them”. A resident stated, “the girls are lovely and when they come to help me to get dress, they never rush me and never make me feel like a nuisance”. Staff were talked to and observed treat residents in a respectful and sensitive manner. They understood the need to promote dignity through practices such as, the way they addressed residents and knocking on bedroom and bathroom doors before entering. Residents’ privacy and dignity are covered during the staff’s induction programme. DS0000025946.V331321.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The residents are able to participate in a varied programme of activities, which suits individual needs, preferences and capacities. Visiting times are flexible and people are made to feel welcome when visiting the home. This ensures that residents are able to maintain contact with their family and friends as they wish. Residents are able to exercise choice and control over their lives. The meals in the home are well presented and nutritionally balanced. They offer both choice and variety to the residents. EVIDENCE: Residents were asked their views and care plans were examined. The signingin book shows that there are visitors to the home every day. Visitors are encouraged to join in activities such as monthly entertainment and other
DS0000025946.V331321.R01.S.doc Version 5.2 Page 14 special occassions. The care plans contain information about preferred activities including spiritual and cultural activities. One resident attends the local church, another receives visits from the local priest, another resident who use to be in a choir, enjoys singing hymns and listening to church music. One of the residents is Jewish but chooses not to follow her religion, however staff talk to her about Jewish events. Activities are based around residents’ individual needs; one activity that takes place is a multi-choice quiz, one of the residents does not like being in a room with other people but she is still able to join in as she is given the quiz to do in her own room. The home has also obtained some DVDs on yoga for another resident, who use to carry out yoga exercises every day. The staff have spent time exploring residents’ wishes and one resident wanted to go to the cinema, she was able to go accompanied by a care worker. At least once a month Abbey Road have a themed evening. Burns night was celebrated in January, all of the dining room tables were covered in the Scottish flag and the flower arrangements were heather and thistles. Residents were able to eat ‘haggis and tatties’, one resident enjoyed the haggis so much she has had it for tea on a couple of occassions since. Scottish music was played and the residents took part in a quiz on Scotland. In February the residents celebrated Shrove Tuesday and many of the residents helped to make the pancakes by stirring the batter and squeezing the lemon juice and sprinkling sugar over the cooked pancakes. Last summer during the World Cup football tournament, each resident picked two teams they wanted to support and the buffet food came from all of those countries. Other themed events have been St Patrick’s Day, Easter Sunday, Wimbledon – strawberries and cream, summer barbeque, harvest lunch, Halloween, Guy Fawkes and a Christmas Party. Outings have also taken place to Clacton, the local Theatre, Valentines Park and a garden centre. The staff are also encouraged to spend time talking to residents on a one to one basis. Visiting times are flexible and visitors confirmed that they could visit at any time. All of the relatives spoken to said that they were made to feel very welcome and they were always offered a cup of tea or coffee. Relatives confirmed that they could see the resident either in one of the lounges or in their own bedroom. Residents’ care plans indicate their preferred name, their choice as to where they take their meals, whether they choose to have a both or shower and their wishes regarding illness or their death. Residents are encouraged to bring in their own personal possessions with them when coming to live at the home and this was evident when the inspector visited residents’ bedrooms. Items such as radios, televisions, photographs, pictures and ornaments enabled the room to feel more homely. Meals are mostly served in the dining rooms, though residents can take their meals in their bedroom if they so wish. The chef has worked at the home for 11 years and is very aware of residents’ likes and dislikes. The meals seen on the day of the inspection looked appetising and nutritionally balanced. There
DS0000025946.V331321.R01.S.doc Version 5.2 Page 15 was a choice of sausages or scampi and different vegetables were also served. Most of the cakes are home cooked and on the day of the inspection some of the residents had helped to make the scones by rolling out the scone mix. Both residents and relatives were extremely complimentary of the food and one relative stated, “the food is better than you get in some top restaurants”. Some of the residents require assistance with eating their meals and staff were seen to carry out this task appropriately, talking to residents and not rushing them. One of the residents does not like eating with others and she sits on a table on her own. DS0000025946.V331321.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 good. This judgement has been made using available evidence including a visit to this service. Residents and their relatives can be confident that their complaints will be listened to and acted upon. There are policies and procedures on adult protection and practices within the home appear to be safe. However to ensure the safety of the residents all of the staff must attend adult protection/abuse awareness training. EVIDENCE: The complaints book was examined during the inspection and no complaints have been recorded since the last inspection. The complaints procedure is on the notice board and four residents were asked ‘if you were unhappy about anything in the home, who would you talk to’? Two residents said Nova (the manager), another residents said she would talk to the staff and another resident said she would tell her family. The majority of the residents have family who are in contact. Only one resident does not have a family or visitors. The manager has referred her to Age Concern for an advocate. Relatives that were spoken to said that they would talk to the manager if they had any concerns and felt confident that they would be listened to and their complaints acted upon. One relative stated “Nothing is too much trouble for Nova and she would act straight away if I had any concerns”. Health professionals who visit
DS0000025946.V331321.R01.S.doc Version 5.2 Page 17 the home were very clear that they would report any concerns or complaints to the manager and would ensure that the concern or complaint was dealt with to their satisfaction. There is a written policy and procedure for dealing with allegations of abuse and whistleblowing. The home also has a copy of the Department of Health’s documents ‘No Secrets’ and the local authority (Redbridge) documentation on adult abuse. Staff that were spoken to were aware of the actions to be taken if there were any concerns regarding the welfare and safety of the residents. Adult protection/Abuse Awareness is dealt with as part of all new staff’s induction programme, however not all staff have attended further training. The manager must ensure that all staff receive regular training in Adult Protection/Abuse awareness. This is Requirement 1. DS0000025946.V331321.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, 23,24,25 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents live in a safe, clean and hygienic environment, however the home is in need of re-decoration and some furnishings need to be replaced to ensure that residents benefit from a pleasant comfortable and well maintained home. Residents’ bedrooms meet their needs and are furnished with their own personal possessions. EVIDENCE: A visit was made to both the kitchen and laundry room, both were maintained to a good standard. Food within the refrigerators and freezers was stored and
DS0000025946.V331321.R01.S.doc Version 5.2 Page 19 labelled appropriately and refrigerator and freezer tempretures are regularly recorded. The living area of the home consists of two lounge/dining rooms (one on each floor) with an additional lounge on the ground floor, from which the garden can be accessed. At the last inspection (November 2005) the manager commented that it had been sometime since the home was redecorated and that this was to be carried out soon, there were also plans for carpets to be replaced as the manager felt the home needed freshening up. At this inspection it was noted that the home was showing signs of wear and tear, walls and doors needed repainting and carpets were stained, also some of the furniture, in particular some of the armchairs in the upstairs lounge need replacing. It was also noted that one of the double glazed windows in the downstairs lounge needed to be replaced. This is Requirement 2. As the ability of people living with dementia to communicate with words decreases, the use of non-verbal cues and the environment are important in enabling them to cope with daily life and orientation. For example, through the use of visual clues such as colour and signage, changes in colour in different areas to assist with orientation, toilet seats that are in a different colour to the rest of the room to assist with identification and using pictorial signs as well as written signs to assist with identifying different rooms. Containers with suitable materials could be located around the home so that residents who can walk can touch and feel things. The use of calming resources such as lighting or a small aquarium could also be used. Appropriate pictures such as pictures of London, that would have been familiar to residents in their younger days, can be used as points of discussion with people with dementia. This is Requirement 3. The garden is well maintained and the residents make full use of this facility in the summer. All bedrooms have en-suite toilets and are furnished with their own furniture and possessions, such as, televisions, radios, ornaments and photographs. The home is cleaned on a daily basis and throughout the inspection all areas of the home, the standard of cleanliness was good. There are adequate control systems in place to ensure that the home is free from any offensive odour. DS0000025946.V331321.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 good. This judgement has been made using available evidence including a visit to this service. The home’s staffing levels are satisfactory and there are sufficient staff on duty, however not all of the staff have the appropriate skills and training to meet the individual needs of the residents. The home has a clear recruitment policy and procedure and appropriate checks are undertaken, which ensures the protection of the residents. EVIDENCE: Staff rotas were examined and the rota correlated with the number of staff on duty, during the day there are four care workers and a qualified nurse on duty. On the day of the inspection there was a sufficient number of staff on duty to meet the needs of the residents. Four staff files were examined and all showed that all the relevant recruitment procedures had been adhered to. All files had a completed application form, two written references, satisfactory Criminal Records Bureau checks, copy of birth certificate and passport were also on file. Two people are involved with interviewing prospective staff and on staff files there was the questions and answers from the interview (answers are scored against a criteria).
DS0000025946.V331321.R01.S.doc Version 5.2 Page 21 All newly appointed staff undertake an induction programme which is in line with Skills for Care. Topics covered during the induction are, moving & handling, first aid, understanding the principals of care, recognising and responding to abuse, equality & diversity, communicating effectively, mental health in later life and maintaining safety at work. All of the care staff have a training plan which records ‘what training has been done’, ‘what training you needs to enable you to do your work’ and ‘what training do you need for your personal development’. Most of the care staff have attended a one-day course on dementia awareness, however the home is registered for people with dementia and the care staff should be attending the three-day course to ensure that they can effectively meet the needs of people living with dementia. There are ten care staff, two of the staff have attained their NVQ 3 and another two have commenced their NVQ 2, the manager must ensure that at least 50 of the care staff attain their NVQ 2. The manager must ensure that the staff are appropriately trained to meet the needs of the residents. This is Requirement 4. The home is not fully staff but the relief bank staff have all worked in the home for some considerable time and are familiar to the residents. A recent advertisement for a nurse, care staff and a domestic post has produced a good response and interviews are going to take place over the next two weeks. Staff that were spoken to stated that they enjoyed working at the home, one care stated, “I absolutely love working here, the staff group is very cohesive, we all get on well. I feel very supported by the nurses and the manager”. Another member of staff stated, “I really enjoy working here, it is the best home I’ve worked in. Nova (manager) is very supportive”. DS0000025946.V331321.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): 31,33,35,36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a home that is run in their best interests by an experienced and qualified manager. Residents’ financial interests are safeguarded by the policies and procedures of the home. There is a system in place to ensure that staff receive regular supervision and yearly appraisals. Residents and staffs’ health, safety and welfare are promoted and protected. DS0000025946.V331321.R01.S.doc Version 5.2 Page 23 EVIDENCE: The manager is a registered nurse and has the relevant clinical and management qualifications. She has many years of experience in providing and managing nursing care services and continues her own personal development by attending further training, she has recently attended a manger’s workshop on Equality and Diversity and NAPA training which looks at activities being identified around residents’ individual needs. She has a very real understanding of the needs of the residents and the areas in which the home needs to improve and further develop. Comments from residents, relatives, staff and other health professionals were extremely complimentary, saying that she is very helpful, supportive and manages the home in the best interest of the residents. The home has a development plan that reflects the aims and outcomes for the residents. Independent auditors have carried out an audit and this is an extract from their report ‘The high scores and the numerous positive comments indicate a very high level of satisfaction among the residents and relatives of Abbey Road’. There is a Quality Assurance (QA) group within the home, which consists of staff, residents and relatives. The group have looked at the home’s policies and also looked at the care plans against the Key Lines of Regulatory Assessment (KLORA) for older people and one of the issues identified was that staff required blind awareness training, which the manager is currently pursuing. The QA group have also looked at staff rotas and again suggestions put forward regarding changes in the rota and the physical placing of the rotas has been taken on board and acted upon. Regular residents and relatives’ meetings also take place. The registered individual under regulation 26 of the Care Home Regulations carries out monthly visits and reports of these visits are available to the Commission. The home has an appropriate policy and procedures regarding the safeguarding of residents’ finances. Residents’ accounts that were checked, showed sound financial procedures are taking place. From discussions with staff and the manager and checking staff files it was evident that regular 1:1 supervision and staff meetings are taking place as well as yearly appraisals. The home has carried out all health and safety checks. All gas and electrical checks have been undertaken within the past 12 months and the lift and fire alarm has been serviced this year. Fire drills and alarm testing are regularly undertaken as are water, freezer and refrigerator temperatures. Staff have DS0000025946.V331321.R01.S.doc Version 5.2 Page 24 undertaken moving and handling training and risk assessments are updated yearly or when a risk is identified. DS0000025946.V331321.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 X 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 2 X 2 3 3 2 3 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 X 3 X 3 3 X 3 DS0000025946.V331321.R01.S.doc Version 5.2 Page 26 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 OP18 Regulation 13 Requirement The manager must ensure that all staff receive regular training in Adult Protection/Abuse Awareness training. The registered persons must ensure that the home is wellmaintained at all times The environment must be suitable to meet the needs of people living with dementia. The manager must ensure that staff receive dementia and NVQ training Timescale for action 30/06/07 2. 3. 4. OP19 OP20 OP22 OP25 OP30 23 23 18(1) 30/09/07 30/09/07 30/06/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations DS0000025946.V331321.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU 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
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