Inspection on 30/05/07 for Abbeydale

This inspection was carried out on 30th May 2007.

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

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

Other inspections for this house

Abbeydale 16/06/08

Abbeydale 21/06/06

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 Key Unannounced Inspection 30th May 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Abbeydale DS0000002104.V338802.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.V338802.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 office@willover.co.uk 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.V338802.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st June 2006 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 originally a private dwelling that has been tastefully and extensively converted into the current nursing home. Residents bedrooms are located across 4 floors. All floors are accessed via a passenger shaft lift and 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, which is not far away, which means that all the amenities of the city centre are within easy reach. The charges made for a room at Abbeydale Nursing Home range from £355.00 a week to £395.00 a week, dependent on the bedroom provided and the needs of the particular Resident. A copy of the Commission’s inspection report is available from within the Home. Abbeydale DS0000002104.V338802.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place in just over 7 hours. Discussion was held with two Residents and both of their relatives or friends, and the records of four Residents were ‘case tracked’. Discussion was also held with Manager of the Home, and with one member of the care staff. A number of records were examined, and the bedrooms of the four Residents whose file were examined, and all public areas of the Home were looked at. The Commission’s pre-inspection questionnaire, sent to the Manager, was examined. The Commission’s Residents questionnaire was also sent to a selection of Residents, and 24 were returned at the time of this inspection. Due to the limitations of the Residents, they had, in the main, been completed with the assistance of relatives. They almost all commented most favourably on the Home, some extremely so. What the service does well: What has improved since the last inspection? It was found that the Registered Providers were now ‘inspecting’ the Home at the required regular intervals of time. The Medic Room was found to be kept locked on this visit to the Home. Abbeydale DS0000002104.V338802.R01.S.doc Version 5.2 Page 6 Improvements had been made to the fabric of the Home, and care staffing levels had been improved and were found to be satisfactory. The Manager had also completed her qualification of NVQ level 4 in Management. 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. Abbeydale DS0000002104.V338802.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.V338802.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): Standards 1, 2, 3 & 6. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. All new Residents moving to the Home were appropriately assessed prior to their admission, so that they were reassured that their needs would be met. EVIDENCE: The Registered Providers had provided a detailed statement of purpose for the Home together with a Resident’s Guide, which was available in each Residents bedroom. The Guide was well completed, although did not provide the opinions of Residents on what life was like in the Home. The Residents Guide also contained information on how contact could be made with the Commission, the local Social Services Dept and the local Health Authority. The records of four Residents were examined during this inspection and a copy of the statement of terms and conditions of residency or a contract, if purchasing their care privately, was found in each file. Abbeydale DS0000002104.V338802.R01.S.doc Version 5.2 Page 9 When new Residents were admitted to the Home, the Manager was provided with a summary of the needs of each person, completed by the Social Services Dept Care Manager supporting each Resident, copies of which were seen. If the Residents were self-funding from the outset, the Manager completed her own summary of needs, which were also seen during the inspection. Standard 6 does not apply to this Home. Abbeydale DS0000002104.V338802.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): Standards 7, 8, 9, 10 & 11. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. Residents’ health and personal care needs were being well met, as demonstrated within care plans. Medication was administered appropriately to meet Residents needs, although improvements were 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. That was, their name and date of birth, their preferred name, their next of kin, their GP, Care Manager and their date of entry to the Home. Very detailed records of the Manager’s initial assessment of each Resident were found in each file, together with well completed Individual Plans of care for each Resident. Records of the risk assessment on each Resident were also found to be available. Abbeydale DS0000002104.V338802.R01.S.doc Version 5.2 Page 11 However, the Manager had not provided information within the files to say what additional needs Residents suffering with dementia might have had. The records should have included details of each Resident’s possible limitations of choice, freedom and decision making. The files showed that very good records of events affecting each Resident were kept by the Home. However, the Manager did not provide formal reviews of Residents care needs at 6 monthly intervals, to which the Resident and their relatives could be invited, although the local Social Services Depts undertook formal review of care on an annual basis. All of the files were easy to read and good entries had been made by the care staff. The Manager said that she reviewed the records of each Resident at regular intervals, but she had not signed the records to indicate that this had taken place. The files were well organised, with different sections and confidential records were maintained when this was felt to be necessary. Throughout the time of the inspection very pleasant conversation was heard to be taking place between staff and Residents. Three staff were also observed assisting Residents with their complete meals, on a one to one basis, before moving on to assist other Residents. Staff 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 was examined. A good system was found to be in use, although the following issues required attention: The Medication Administration Record (MAR) sheets contained a number of handwritten entries completed by staff from the Home. These additional medications had not been signed by two staff, to confirm the correct entry had been made, and did not contain the name of the Doctor who authorised the medication, or the date on which the new medication was to start/had started. When the MAR sheet stated that a medication, such as Sudecream or other gels were to be provided, staff were found to not be signing the MAR sheet to indicated that such creams had been applied to the relevant Resident. 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 also said that their care needs were always met with dignity and respect. As a result, they felt very safe in Abbeydale DS0000002104.V338802.R01.S.doc Version 5.2 Page 12 the Home, and appeared to have a strong sense and appearance of well being – ‘Most staff do things my way, especially day time staff.’ This Resident was very concerned by the poor care she said she received at night. As a result she said she was frightened of needing night assistance in case a particular care assistance came to meet that need. This issue was later discussed with the Manager, who agreed to enquire into the issues raised. A member of staff was spoken to, and she described very positive ways Residents were assisted within the Home. She said that a telephone was always available for Residents use, which was usually the Home’s telephone. A Resident, the Resident’s visiting friend, and the staff member said that mail was delivered to the Residents unopened. The staff member said that all clothing was appropriately marked with each Resident’s name, which was seen in the laundry. She also said that the term of address requested by each Resident was always used, even were the Resident requested to be formally addressed as Mrs or Mr. She commented on the importance of the Home’s induction package for staff, that helped ensure that Residents were treated with respect at all times. When assisting Residents who were dying, the member of staff said that the Resident’s choice of treatment was always respected. She also describe the care provided following the death of a Resident, which was most appropriate. Abbeydale DS0000002104.V338802.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): Standard 12, 13, 14 & 15. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. Residents preferred lifestyles were respected by the Home, and Residents were given a wholesome and appealing diet in pleasant surroundings, that enhanced Residents well being. EVIDENCE: Residents were asked about the activities provided in the Home. They were able to say that an Activities Coordinator arranges these events, which included singers calling, trips out, which were much enjoyed, and events taking place in the Home. Staff said that the Activities Coordinator also arranged exercises for Residents, bingo, and tombola events. Residents said that they decided when they got up and went to bed – ‘I choose when to get up, although staff help me into my night clothes early, at about 7.00, but I choose when to go to bed. One Resident also said ‘I have one bath a week, although I would like more.’ Relatives and friends of Residents were able to visit at any time, and could always be seen in private - ‘Yes, I always see my friend in private.’ This was also confirmed by the ‘friend’, and by staff. Abbeydale DS0000002104.V338802.R01.S.doc Version 5.2 Page 14 A member of staff said that new Residents could bring any item of furniture with them to the Home, as long as it fitted within their bedroom. Residents were able to say that the Home provided good meals and that a choice was available at breakfast and teatime meals. However, at dinner time only one meal was offered, although if the meal was disliked an alternative would be offered. The staff spoken to confirmed this. Staff also said that drinks and snacks were always provided between meals for Residents, and that mealtimes were never rushed. Abbeydale DS0000002104.V338802.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 16 & 18. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. Complaints made to the Registered Providers or Manager were addressed to meet Residents needs. The protection policies and procedures provided meant that Residents were well protected. EVIDENCE: A visitor to the Home said that if they or the person visited had a complaint to make they would tell the Manager. The Commission had not received any notice of complaint since the last visit to the Home, in June 2006. Since that visit, the Manager had recorded two concerns raised by Residents and visitors. These were reviewed and were found to have been satisfactorily dealt with. Good procedures were seen for both written and verbal complaints, and it was found that at least one Registered Provider was always involved with any concern or complaint raised. The Registered Providers complaints procedure detailed that all complaints would be responded to by a Registered Provider or the Manager within at least 28 days. The Registered Providers had a Safeguarding Adults procedure that included a ‘Whistle Blowing’ policy. The Home also had a copy of the Public Interest Disclosure Act of 1998, and of the Dept of Health’s policy called ‘No Secrets’ available in the Home. The Manager confirmed that all allegations and Abbeydale DS0000002104.V338802.R01.S.doc Version 5.2 Page 16 incidents of abuse would be promptly followed up and that all actions taken would be recorded. So far, however, this procedure had not been needed. The policies and practices laid down by the Registered Providers ensured that all staff understood physical and verbal aggression by Residents. The Manager also said that a policy was available to staff stating that they could not benefit from Residents wills, which was also understood by the staff spoken. Abbeydale DS0000002104.V338802.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 20, 21, 22, 23, 24, 25 & 26. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. The Home was well maintained throughout, providing all Residents with a safe, comfortable environment in which to live. EVIDENCE: A tour was made of the public areas of the Home, and included the four bedrooms of the Residents whose care was also reviewed at the time of this visit. The Home was attractively decorated throughout, and the lounges and dining room were pleasant to sit in, and were provided with the appropriate items for the Residents. The bedrooms seen provided very good space and provision for each Resident. The Registered Providers had provided appropriate furnishings in all locations seen during this visit. Abbeydale DS0000002104.V338802.R01.S.doc Version 5.2 Page 18 Toilets were easily available to all Residents, were clearly marked, and were provided with handrails where necessary. A call system was also available throughout the Home. The Home had appropriate sluicing facilities, and laundry was washed at appropriate temperatures. The name of the Keyworker for each Resident was seen posted on the wall of the four Residents bedrooms visited. However, the following three items needed addressing within the Home: Two shower rooms were seen to be full of ‘equipment’, needed by the Home, making the shower facilities unusable. The Home was also provided with at least two medic-baths, which the Manager said were not used. As a result of this, the Manager agreed that the Home did not have enough bathing facilities operational for the number of Residents within the Home. The majority of bedroom doors throughout the Home had not been fitted with locks that could be operated by Residents from both the inside and outside of the bedroom. Should this be addressed care staff and domestic staff would need to be provided with masterkeys to allow them entrance to the bedrooms. In some bedrooms the radiators were found to be unsafe for Residents and so needed to be reviewed. Abbeydale DS0000002104.V338802.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 & 30. The quality in this outcome area was Adequate. This judgement was made using available evidence including a visit to this service. Appropriate levels of care staffing was provided, although recruitment practices needed to be improve to ensure that Residents were protected at all times. EVIDENCE: A good level of staffing was found to be provided in the Home to meet the needs of Residents. At the time of this visit to the Home it was found that under 50 of care staff had a qualification of at least NVQ level 2 in Care: 6 out of a total of 21 care staff. However, the Manager was able to say that a further 2 staff were currently working towards obtaining the qualification, and that 6 more staff would be starting their NVQ training in June 2007. She therefore anticipated that more than 50 would hold the qualification of at least NVQ level 2 in Care by the end of March 2008. The records of two new staff employed during the past 12 months 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, no references had been obtained for one member of staff and only one reference had been obtained for the other staff member. A photograph had not been obtained of these members of staff either. All other information was found to be satisfactory. Abbeydale DS0000002104.V338802.R01.S.doc Version 5.2 Page 20 The Manager said that new staff would be provided with induction and foundation training. She also said that all care staff were provided with at least three paid days training a year, and a member of the care staff supported this, indicating that more than three days of training were provided each year. The records of some of this training was seen. All staff also had an individual training and development assessment and profile. Abbeydale DS0000002104.V338802.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 36 & 38. The quality in this outcome area was Adequate. This judgement was made using available evidence including a visit to this service. Management arrangements at the Home were not sufficiently robust to ensure that residential care was maintained at a positive standard. EVIDENCE: The Manager was a qualified nurse and held an NVQ level 4 qualification in Management. The Registered Provides were also found to be completing the formal ‘inspections’ of the Home, as required by Regulation 26. The Manager was able to show the annual development plan for the Home, completed in conjunction with one of the Registered Providers, that reflected the aims and outcomes for Residents had been completed. Surveys had been undertaken of Residents opinions of the operation of the Home, and these had been published and could be found on the Home’s notice board. The Manager Abbeydale DS0000002104.V338802.R01.S.doc Version 5.2 Page 22 also said that she discussed with Residents the operation of the Home at Residents meetings, but did not have copies of minutes to show that this was done. She also stated that she and the staff would be able to demonstrate the Home’s commitment to lifelong learning and development of each Resident in the Home. This was confirmed by staff spoken to during the visit to the Home. However, the opinions of Residents families and friends or of GPs and District Nurses were not obtained on how well they thought the Home was achieving goals for Residents. The Manager stated that the Home did not hold any savings money on behalf of Residents. Residents purchases and hairdressing etc were paid by the Home and relatives were then billed for these amounts. Staff were asked about the regularity of supervision in the Home. The staff said that some of them had regular supervision, amounting to approximately four times a year, while other staff said that no supervision was provided. This was later confirmed by the Manager, agreeing that where supervision was provided it operated four times a year. The training required by the Regulations was examined. This showed that Moving and Handling training and Fire Safety training had been provided. However, 6 staff were found to need training in First Aid and 15 staff needed up to date training in Food Hygiene. 10 staff also needed training in Infection Control. From copies of the Home’s maintenance schedule, forwarded to the Commission prior to the inspection, it was found that all necessary maintenance and repairs were being appropriately addressed. All Residents had been risk assessed to determine their vulnerability and measures had been put in place to provide protection where necessary. The Registered Providers 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 was not able to show that she had provided risk assessments on all safe working practices of staff; that is for care staff, catering staff and domestic staff. Nor had she provided a written statement of the policy, organisation and arrangements for maintaining these safe working practices. Finally, the Manager was able to show that all accidents, injuries and incidents of illness or communicable disease were recorded and reported to the relevant government bodies. With the assistance of the Fire Service, fire safety notices were also posted in relevant places around the Home. Abbeydale DS0000002104.V338802.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 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 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 2 3 3 2 2 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 X 2 Abbeydale DS0000002104.V338802.R01.S.doc Version 5.2 Page 24 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 OP7 Regulation 17(1)(a) & Sch. 3 3(q) Requirement The Manager must ensure that each Resident, or their representative, has the opportunity to discuss their rights to choice, freedom and decision-making while staying in the Home. The outcome must be recorded in each Resident’s records. If an alteration or an additional medication is necessary on the Medication Administration Record (MAR) sheet, this must always be signed by two staff, dated and state the name of the Doctor authorising the change to the medication. When prescribed creams or gels are applied to Residents skin the MAR sheet must always be signed. (This issue is outstanding from the inspection report of 21 June 2006) 3. OP12 12(1)(a) & (b) The concerns of a Resident regarding the care provided by care staff working at night must DS0000002104.V338802.R01.S.doc Timescale for action 25/07/07 2. OP9 13(2) 25/07/07 25/07/07 Abbeydale Version 5.2 Page 25 be resolved. 4. 5. OP21 23(2)(j) 23(2)(p) Sufficient bathing facilities must be provided within the Home. Risk assessments on all radiators must be carried out to ensure that Residents are unlikely to scald themselves by accidentally falling against them. Radiator guards must be provided were Residents are found to be at risk. (This issue is outstanding from the inspection report of 8 November 2005) The Manager must ensure, when appointing new staff, that all the requirements listed in Regulation 19 and Schedule 2 of the Care Homes Regulations 2001, as amended during 2004, are obtained. Of two staff’s records examined it was found that insuffiecient references had been obtained and no photographs were provided of the new staff. When completing quality assurance information on the operation of the Home, information should be obtained from Residents relatives and friends, from GPs and District Nurses on how well the Home is achieving goals for Residents. Supervision must be provided for all care staff. All staff without the training or are out of time for training must received training in First Aid, Food Hygiene and Infection Control. 31/10/07 31/10/07 OP25 6. OP29 19 25/07/07 7. OP33 24 30/09/07 8. 9. OP36 OP38 18(2) 18(1)(c) (i) 25/07/07 30/11/07 Abbeydale DS0000002104.V338802.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Refer to Standard OP1 OP7 No. 1. 2. Good Practice Recommendations The Residents Guide should contain the views of Residents on what it is like to live in the Home. 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. One of these reviews, each year, could be conducted by the Social Services Dept, although the Manager should provide formal written input to the review of the welfare and care provide to the Resident. When the Manager has reviewed a Resident’s file, she could indicate that this has been done by signing the record with a red or green pen. (These two issues are outstanding from the inspection report of 21 June 2006) 3. OP8 A record should be maintained of all meals taken by each Resident staying in the Home. (This issue is outstanding from the inspection report of 21 June 2006) A choice of meals should be provided at lunchtime meals. All Residents bedroom doors should be fitted with locks, operational from both the inside and outside of the bedroom. If this is provided care staff and domestic staff should be provided with master keys to Residents bedrooms. (This issue is outstanding from the inspection report of 21 June 2006) The Registered Providers should ensure that at least 50 of care staff are trained to NVQ level 2 in Care at all time. (This issue is outstanding from the inspection report DS0000002104.V338802.R01.S.doc Version 5.2 Page 27 4. 5. OP15 OP24 6. OP28 Abbeydale of 21 June 2006) 7. 8. OP36 OP38 Supervision should be provided for all care staff at least 6 times a year. The Manager should 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 also provide a written statement of the policy, organisation and arrangements for maintaining safe working practices in the Home. (These two issues are outstanding from the inspection report of 21 June 2006) Abbeydale DS0000002104.V338802.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Abbeydale DS0000002104.V338802.R01.S.doc Version 5.2 Page 29 - 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!