Inspection on 21/06/06 for Abbeydale

This inspection was carried out on 21st June 2006.

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

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

Other inspections for this house

Abbeydale 16/06/08

Abbeydale 30/05/07

Abbeydale 11/11/05

Abbeydale 06/07/04

Abbeydale 08/07/02

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Abbeydale 182 Duffield Road Derby DE22 1BJ Lead Inspector Steve Smith Unannounced Inspection 10:00 21st June 2006 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 Abbeydale DS0000002104.V299235.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. Abbeydale DS0000002104.V299235.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbeydale Address 182 Duffield Road Derby DE22 1BJ 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) 01332 331182 01332 344481 Willover Limited Pamela Margaret Slonimski Care Home 41 Category(ies) of Old age, not falling within any other category registration, with number (41) of places Abbeydale DS0000002104.V299235.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th November 2005 Brief Description of the Service: Abbeydale Nursing Home provides 41 places for Residents over the age of 65 years and is situated in a residential area of Derby city. The property was orginally a private dwelling that has been tastefully and extensively converted into the current nursing home. Residents bedrooms are located over 4 floors. All floors are accessed via a passenger shaft lift or staircase. Four shared bedrooms have ensuite facilities. The Home is close to a local park, churches and public houses. It is also on a regular bus route from Derby city centre that is not far away, which means that all the amenities of the city centre are within easy reach. Abbeydale DS0000002104.V299235.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place in just over 6 hours. Discussion was held with the Manager and with two Residents, whose records were also ‘case tracked’. Some of the Home’s records were examined, and all public areas and many bedrooms were examined. The fees for staying within the Home range from £415.00 a week, for a shared double room, to a maximum of £650.00 a week for a particular large single room with ensuite facilities. Other single rooms range between these two figures. What the service does well: The issues mentioned in these next three sections of the report were the items inspected on this visit to the Home. The Registered Providers had ensured that the Home had a completed statement of purpose and Residents Guide, and all new Residents moving to the Home were appropriately assessed. Good records of care were maintained, as were the health care needs of the Residents. Good records were also maintained of the distribution of medication. Two Residents were interviewed during this inspection, and they were most complimentary of staff, saying that their care needs were always well met. The Manager provided a prompt complaints procedure, and ensured that a good Adult Protection procedure operated within the Home. The Home was also maintained to a good standard throughout. A satisfactory level of staffing was provided within in the Home, often exceeding the minimum standards set by the Residential Forum. Staffing was well trained to meet the needs of Residents. All Residents in the Home had been provided with a risk assessment to help in determining their safety. All accidents, injuries and incidents of illness or communicable diseases were recorded and reported to the relevant government bodies. The Home also ensured that fire safety notices were posted in relevant places around the Home. Abbeydale DS0000002104.V299235.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. Abbeydale DS0000002104.V299235.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 Abbeydale DS0000002104.V299235.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 2 & 3. The quality in this outcome group was ‘Good’. This judgement was made using available evidence including a visit to the Home. The Registered Providers statement of purpose and Residents Guide were appropriately completed. All new Residents moving to the Home were appropriately assessed prior to their admission. EVIDENCE: The Registered Providers had provided a statement of purpose for the Home together with a Residents Guide. Both these documents had been appropriately completed, and included details of how to contact the Commission, the local Social Services Dept and the local Health Authority. All Residents had been provided with copies of the statement of terms and conditions of residency in the Home or a contract if purchasing their care privately. Abbeydale DS0000002104.V299235.R01.S.doc Version 5.2 Page 9 When new Residents were admitted to the Home, the Manager was provided with a summary of needs of each person, completed by the Social Services Dept Care Manager supporting each Resident. If the Resident was self-funding from the outset, the Manager said she would complete her own summary of needs. Standard 6 does not apply to this Home. Abbeydale DS0000002104.V299235.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 & 10. The quality in this outcome group was ‘Good’. This judgement was made using available evidence including a visit to the Home. Residents’ health and personal care needs were being fully met, as demonstrated within care plans. Medication was appropriately distributed to meet Residents needs, although a minor improvement was required. EVIDENCE: To help assess Standard 7, the Resident’s Plan of Care, the records of four Residents were examined, for the purpose of case tracking. All of the basic information, concerning each Resident, was found to be in the files examined. Copies of the initial assessment completed by the Social Services Care Manager that placed each Resident at the Home were available, and the Manager had completed her own initial assessment of needs for each of the four Residents. There were also copies of the ongoing care plan and risk assessment available in each file examined. However, the Manager had not provided written details of Abbeydale DS0000002104.V299235.R01.S.doc Version 5.2 Page 11 each Resident’s possible limitations of choice, freedom or decision making abilities, at each formal review held in the Home. The files showed that records of events affecting each Resident were kept by the Home. The Residents’ formal reviews of care, undertaken annually by the Social Services Dept had been shown to, and been signed by each Resident, or their representative. However, formal six monthly reviews of care were not undertaken by the Manager, despite being recommended to do so by the Commission. All of the files contained a confidential section, were easy to read, were well organised and were kept in a safe location. However, they were not regularly reviewed by the Manager. When this was done she could indicate this with her signature in the records. Within the daily record of events in three of the files, a senior member of staff was found to have asked other staff to monitor the condition of the Resident. However, subsequent entries in the records did not refer to these requests, so it was not possible to see any outcome of the requests to ‘monitor’. Staff of the Home were appropriately maintaining the records of Residents health needs, although a record of nutrition taken within the Home was not being maintained for each Resident. All medication and the method of distributing it to Residents were examined, and a good record was found. However, the following two issues needed attention: A number of signature gaps were found on the Medication Administration Record (MAR) sheets when drugs or liquids had been prescribed. No signatures were found on the MAR sheets when creams, of whatever nature, had been applied to Residents skin, therefore there was no indication that the cream had been applied at the required frequency. Two Residents were spoken to about life in the Home. They said that staff were very good at listening to their views on how they liked to be cared for and staff would carry out their wishes. They said that their care needs were always met with dignity and respect. As a result, they felt very safe in the Home, and appeared to have a strong sense and appearance of well being. The relatives of one of the Resident’s were able to very strongly confirm this. This is a very good home. Abbeydale DS0000002104.V299235.R01.S.doc Version 5.2 Page 12 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): Standards 12, 13, 14 & 15. The quality in this outcome group was ‘Good’. This judgement was made using available evidence including a visit to the Home. Residents preferred lifestyles were respected by the Home. They were able to receive visitors and to exercise choice and control over their lives. Residents were given a wholesome and appealing diet in pleasant surroundings. EVIDENCE: Two Residents was asked about the activities provided in the Home. They said that events included such things as dominos, music and outing. During the inspection a number of Residents were seen to take part in a game of bingo, during which prizes were given to those Residents that won each game. The bingo was organised by an Activities Coordinator, who visited the Home a number of days each week, providing group activities and individual activities throughout the Home. Both Resident said that they could go to bed and get up at times of their own choosing. ‘I can get up when I like, which is usually very early’, the second Resident said ‘I go to bed at 11.00 o’clock. Abbeydale DS0000002104.V299235.R01.S.doc Version 5.2 Page 13 Residents also said that meals were always good. ‘Two (choices) of every thing is always provided’. Dinnertime was observed during the inspection, and three staff were seen to provide disabled Residents with their meals. This was done most appropriately, with the member of staff assisting with the complete meal before moving to another Resident to meet their mealtime needs. Both Residents said that they knew whom their keyworker was, and the name of the keyworker was seen to be posted on the wall of each bedroom. One of the Residents said that she was to ill to go out shopping, but believed that she go do this if she was well enough. The second Resident said that Priests regularly visited the Home and provided communion for her. Relatives and friends of Residents were able to visit at any time, and could always be seen in private. One Resident was being visited by family members at the time of this inspection, and the family members said that visits are made ‘on a daily basis’. Both Residents very confidently said that staff always knocked upon their bedroom doors and waited to be invited in. They also said that their mail was always delivered unopened, and that this was a ‘non-smoking’ home, although Residents could smoke outside if they wished. Abbeydale DS0000002104.V299235.R01.S.doc Version 5.2 Page 14 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): Standards 16 & 18. The quality in this outcome group was ‘Good’. This judgement was made using available evidence including a visit to the Home. Complaints made to the Registered Providers and Manager were appropriately addressed to meet Residents needs. The protection policies and procedures provided by the Home meant that Residents were well protected. EVIDENCE: One of the Residents spoken to said that if she had any issues of complaint she would take them to the Manager. The other Resident said that she would tell her relatives, who in turn said that they would discuss her concerns with the Manager. The Commission had received one notice of complaint since the last inspection in November 2005. An Inspector visited the Home to attend the case conference on this issue, which was handled competently, and sensitively, by the Registered Provider and Manager. The Social Services Dept who organised the case conference recorded that there was no issue for the Home to answer. Good procedures and satisfactory records were maintained of both verbal and written complaints. They showed that the Manager maintained a good system for Residents complaints and that both written and verbal complaints were recorded. The Home’s record also detailed that all complaints would be responded to by the Registered Providers within at least 28 days. Abbeydale DS0000002104.V299235.R01.S.doc Version 5.2 Page 15 The Manager had an Adult Protection procedure that included a ‘Whistle Blowing’ policy. She also had copies of the Public Interest Disclosure Act of 1998 and the Dept of Health’s policy called ‘No Secrets’. She was able to confirm that she would follow up all allegations and incidents of abuse promptly and that all actions taken would be recorded. The policies and practices laid down by the Registered Provider and Manager ensured that all staff understood physical and verbal aggression by Residents. The Manager also said that there was a policy available to staff stating that they could not benefit from Residents wills. Abbeydale DS0000002104.V299235.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 20, 21, 22, 23, 24, 25, 26. The quality in this outcome group was ‘Good’. This judgement was made using available evidence including a visit to the Home. The Home was well maintained throughout, providing all Residents with a safe, comfortable environment in which to live, although some attention was needed within this sector. EVIDENCE: A tour was made of the Home, including a number of bedrooms of the Residents. The Home was well decorated throughout, and the four lounges were provided with appropriate items for the Residents. The kitchen was also inspected and found to be well presented. The laundry was seen, and all clothing was appropriately marked with Residents names or room number. However, some clothing had been marked with a felt-tip marker on the clothing itself, which would show through when the item was worn. Abbeydale DS0000002104.V299235.R01.S.doc Version 5.2 Page 17 The Medic Room was also examined. This room was found to be unlocked, with the cupboards also unlocked, leaving medication at risk of being removed or taken by confused Residents. The bedrooms were well laid out with good space provided for each Resident. Appropriate furniture was provided in the bedrooms or the Resident had been asked whether they required additional items. However, a number of items needed attention: In the first toilet, at the foot of the main staircase, the staff call line was not working. In the third toilet, at the foot of the main staircase, the linoleum floor covering was rucked up and needed repair. In many single bedrooms in the Home only three electric sockets had been provided, rather than the recommended two double sockets (four sockets). In the double bedrooms seen only four individual sockets were provided rather than the recommended four double sockets (eight sockets). In two of the toilets seen the staff call line had been put out of reach of Residents. No bedroom doors in the Home had been fitted with a lock that the Resident could operate, if they so chose. This was the case at the last inspection of the Home in November 2005. Again in November 2005, radiators throughout the Home needed to be risk assessed and where necessary, for example in Residents bedrooms, provided with protective measures to prevent Residents from burning or scalding themselves. However, the Registered Providers had not addressed this. Abbeydale DS0000002104.V299235.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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): Standards 27, 28, 29 & 30. The quality in this outcome group was ‘Good’. This judgement was made using available evidence including a visit to the Home. Care staffing was appropriately provided to meet the needs of Residents, although some attention was needed in this area. The Manager also needed to ensure that references were always obtained when employing new members of staff to safeguard Residents. EVIDENCE: Staffing provided in the Home was compared with the details provided by the Residential Forum. This showed that during the three weeks beginning 22 May to the 5 June 2006 the Home was providing care at three levels. During week beginning 22 May 2006 care was provided for 17 Residents at the High Dependency level and 24 Residents at the Medium Dependency level. During week commencing 29 May 2006 care was provided for 35 Residents at the High Dependency level and 6 at the Medium Dependency level, and during week commencing 5 June 2006, 21 Residents at the High Dependency level and 20 at the Medium Dependency level. The Registered Providers and Manager were asked to review the provision of care for the week commencing 22 May as this was considered to be to low given the Resident group staying within the Home. These figures were calculated without the Manager’s working time included, as recommended by the Residential Forum. Abbeydale DS0000002104.V299235.R01.S.doc Version 5.2 Page 19 Across the three weeks reviewed, 10 separate staff were found to have worked at least one double shifts and sometimes more, amounting to 13 hours in one day. This does not encourage staff to meet the needs of Residents in a kindly, understanding and patient manner, and is to be strongly discouraged. At the time of this inspection it was found that just short of 50 of care staff had a qualification of at least NVQ 2 in Care. However, some of those care staff without the qualification were undergoing training. The records of two new staff employed since April 2002 were examined to see whether the Manager had obtained all relevant information about them. It was found that almost all information had been obtained. However, she had not obtained two written references for either member of staff. All other records were satisfactory. Staff induction and foundation training was provided for all new staff that came to work in the Home. The Manager also said that all care and nursing staff were provided with at least three paid days training a year. All staff also had an individual training and development assessment and profile. Abbeydale DS0000002104.V299235.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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): Standards 31, 33, 35, 36 & 38. The quality in this outcome group was ‘Adequate’. This judgement was made using available evidence including a visit to the Home. The Manager needed to obtain an NVQ level 4 qualification in Management to ensure Residents needs were appropriately met. The Manager also needed to complete the Quality Assurance issues to ensure Residents care was maintained at a positive standard throughout the Home. EVIDENCE: The Manager had not as yet completed her NVQ level 4 qualification in Management. She anticipated completing the course by 31 January 2007. One of the Registered Providers regularly visited the Home on at least a weekly basis and reviewed its operation. However, this did not include providing a written report on the Home as required by Regulation 26. Abbeydale DS0000002104.V299235.R01.S.doc Version 5.2 Page 21 The Manager was able to show the results of surveys on the operation of the Home. These included surveys of Residents and of their relatives. The Manager had also begun to create an annual development plan for the Home, but this required much more attention before it could be fully operational. The Home does not hold money on Residents behalf. Should Residents need access to money this was supplied by relatives, or the Home might loan the money pending repayment by the relatives from the Residents savings. Supervision of the care staff was undertaken by the nursing staff, with the Manager in turn supervising the nursing staff group. The training provided for staff was examined. This showed that Moving and Handling training, Fire training, First Aid training, Food Hygiene and Infection Control training would all be up to date by the end of July 2006. All Residents had been risk assessed to determine their vulnerability and measures had been put in place to provide protection where necessary. The Home had complied with all necessary legislation, such as the Health and Safety at Work Act 1974, and the Manual Handling legislation of 1992. The Manager had not provided risk assessments on the working conditions of staff; that is for care staff, catering staff and domestic staff. She had also not provided a written statement of the policy, organisation and arrangements for maintaining the safe working practices in the Home. These two issues were outstanding from the inspection report of November 2005. The Manager ensured that all accidents, injuries and incidents of illness or communicable disease were recorded and reported to the relevant government bodies. She had also ensured, with the assistance of the Fire Service that fire safety notices were posted in relevant places around the Home. Abbeydale DS0000002104.V299235.R01.S.doc Version 5.2 Page 22 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 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 3 2 3 3 3 3 2 2 3 STAFFING Standard No Score 27 2 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 3 X 2 Abbeydale DS0000002104.V299235.R01.S.doc Version 5.2 Page 23 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 OP9 Regulation 13 Requirement When signature gaps are left on the Medication Administration Record (MAR) sheets the Manager should mark the gap and record on the back of the MAR sheet the reason why the gap had occurred and what she has done about it. When prescribed creams are applied to Residents skin the MAR sheet must always be signed. 2. OP25 13 Radiators throughout the Home must be risk assessed and any necessary protective measures introduced to prevent Residents from being scalded or burned. (This issue should have been addressed from the inspection report dated 8 November 2005) The Registered Providers and Manager must check, and hold documentary evidence, that all new staff employed have satisfied the requirements listed in Regulation 19 and Schedule 2 DS0000002104.V299235.R01.S.doc Timescale for action 16/08/06 16/08/06 3. OP29 19 16/08/06 Abbeydale Version 5.2 Page 24 of the Care Homes Regulations 2001, amended in 2004. 4. OP31 26 The Registered Providers must ‘inspect’ the Home and provide written details of their visit in line with Regulation 26 on at least a monthly basis. 16/08/06 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 OP7 Good Practice Recommendations The Manager should ensure that each Resident, or their representative, has had the opportunity to discuss their rights to choice, freedom and decision-making while staying in the Home. The outcome needs to be recorded in each Resident’s records. Formal reviews of care should be undertaken at 6 monthly intervals. Those taking part should at least include staff from the Home, the Resident and their relatives, particularly the ‘personal representative’. The review of care should be shown to the Resident (or representative) for signature. The Manager should review each Resident’s file on a least a monthly basis. She could indicate that this has been done by signing the record with a red or green pen. When nursing staff use the Resident’s record of events to ask other staff to carry out tasks, the task should be addressed on each entry following until the staff member requesting the task signs it off as no longer needed. A record should be maintained of all meals taken by each Resident staying in the Home. The Medic Room should be kept locked at all times. 2. OP7 3. OP7 4. OP7 5. 6. OP8 OP9 & OP19 Abbeydale DS0000002104.V299235.R01.S.doc Version 5.2 Page 25 7. OP19 In the laundry, Residents clothing should not be marked with a felt-tip marker as this shows through the clothing when it is worn. In the first toilet, at the foot of the main staircase, the staff call line should be repaired. In the third toilet, at the foot of the main staircase, the linoleum floor covering was rucked up and should be repaired. In all single bedrooms at least two double sockets should be provided and in all double bedrooms at least four double sockets should be provided. In all toilets the staff call line needs to be within easy reach of Residents. All bedroom doors should be fitted with a lock that can be operated from both the inside and outside of the room by the Resident. Each Resident should be provided with a key to their bedroom. Risk assessments need to be carried out and recorded in the Resident’s file where it is considered by the Registered Providers that the Resident is not able to hold the key to their bedroom. All care staff and domestic staff should be provided with master keys to Residents bedrooms. 8. 9. OP19 OP19 10. OP19 11. 12. OP19 OP24 13. OP27 Care staffing levels provided within the Home should always be at least equal to that recommended by the Residential Forum. The Registered Providers and Manager should review the length of time nursing and care staff are allowed to work in the Home, and where possible limit this to no more than one shift per day, of approximately 8 hours, and 40 hours each week. The Registered Providers should ensure that at least 50 of care staff are trained to NVQ level 2 in Care as soon as possible. The Manager should obtain a qualification at NVQ level 4 in Management by 31 January 2007. A full quality assurance system as set out in Standard 33 of the National Minimum Standards should be developed. DS0000002104.V299235.R01.S.doc Version 5.2 Page 26 14. OP27 15. OP28 16. 17. Abbeydale OP31 OP33 In particular Standards 33.2 and 33.5. 18. OP38 The Manager must provide risk assessments, for all staff, on all working practice topics in order to ensure that significant findings are recorded and acted upon. The Manager should provide a written statement of the policy, organisation and arrangements for maintaining safe working practices in the Home. Abbeydale DS0000002104.V299235.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Abbeydale DS0000002104.V299235.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!