Inspection on 12/06/06 for Abbeydale Nursing and Residential Care Home

This inspection was carried out on 12th 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 Nursing and... 02/10/07

Abbeydale Nursing and... 02/01/07

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Chirnside House

Sunny Bank (P.R.S.) Ltd

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Ashwood Court Unit 1

Langrigg House

Parkside

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

CARE HOMES FOR OLDER PEOPLE Abbeydale Nursing and Residential Care Home Croylands Street Kirkdale Liverpool Merseyside L4 3QS Lead Inspector Les Smith Unannounced Inspection 12th June 2006 09:00 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 Nursing and Residential Care Home DS0000067386.V288884.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 Nursing and Residential Care Home DS0000067386.V288884.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbeydale Nursing and Residential Care Home Address Croylands Street Kirkdale Liverpool Merseyside L4 3QS 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) Care Home 36 Doson Limited Category(ies) of Dementia - over 65 years of age (36), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (36), Old age, not falling within any other category (36), Physical disability over 65 years of age (36) Abbeydale Nursing and Residential Care Home DS0000067386.V288884.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 36 nursing care and 36 personal care in the overall number of 36 Three named service users under the age of 65 That an individual be appointed to manage the home within a period of not more than three months from the date of registration. Date of last inspection Brief Description of the Service: Abbeydale is a care home registered to provide residential or nursing care for 36 older people. The ownership of the home changed on 31st March 2006. the home remains privately owned and the owners are in the process of appointing a manager who will then apply for registration with the CSCI. The home is located in the Kirkdale area of Liverpool and has easy access to bus routes, churches, shops and other local amenities. Abbeydale was originally a school and retains the outward appearance of a school building. Converted into a care home some eleven years ago it has car parking to the front and an enclosed well maintained rear garden. Accommodation is provided in single bedrooms on three floors. Access is all floors is provided via a passenger lift and stairways. Fees at Abbeydale Nursing and Residential Care home range from £385 to £490 depending upon service required. Abbeydale Nursing and Residential Care Home DS0000067386.V288884.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 over one day for a period of eight hours. The inspector examined care records and associated documents, staff files, management records and had discussions with staff of all grades, residents and visitors to the home. A tour of the home was made accompanied by the acting manager. All residents appeared well cared for and staff were observed delivering care in a sensitive and dignified manner. The recent changes in ownership have resulted in changes, which have being well received and staff have a positive attitude in relation to the future. Relatives spoken to appeared happy with the service with comments such as ‘the staff are very caring’ and ‘mum is very settled and I am happy with her care’. What the service does well: 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 Nursing and Residential Care Home DS0000067386.V288884.R01.S.doc Version 5.2 Page 6 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 Nursing and Residential Care Home DS0000067386.V288884.R01.S.doc Version 5.2 Page 7 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): 1,3,5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective residents and their representatives have sufficient information to make an informed decision about where they wish to live but cannot be confident that their needs will be fully assessed prior to accepting a place at the home. EVIDENCE: The new owner of the home has produced new Statement of Purpose and Service User Guide documents. These are well presented and easy to read and both contain all the required elements. However both documents include the details of the previous manager and this needs to be reviewed to reflect the current management arrangements. Following review the service users guide must be distributed to all residents or their representatives as appropriate so that they are kept fully informed. Pre-admission assessments seen lacked the information required to construct a robust initial care plan. Assessments seen identified areas were assistance was required but gave no detail of care intervention required. Information on preferred social interaction and recreational activities was negligible as was Abbeydale Nursing and Residential Care Home DS0000067386.V288884.R01.S.doc Version 5.2 Page 8 information on cognitive ability. One file examined had a re-assessment carried out in April 2006. This also demonstrated a poor standard of assessment and documentation. Pre-admission assessments are the means of establishing the homes capacity to deliver the care required and provides reassurance to the prospective resident and their representative that the assessed needs can be met. The home is in the process of renewing much of the documentation used in all aspects of care management and this may well address the short fall identified with pre-admission assessments. Prospective residents and their representatives are welcomed at the home at any time to assess the quality, facilities and general suitability of the home and are welcome to visit as often and for as long as they wish. The home is not registered for intermediate care. Abbeydale Nursing and Residential Care Home DS0000067386.V288884.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The lack of comprehensive and consistent care planning, risk assessment and review fails to promote the service user’s health, personal and social care needs. Medication administration is not in accordance with current regulations and best practice guidelines and may place residents at risk of harm. EVIDENCE: A range of care plans and associated documentation were examined on the day of inspection. These included residents with differing needs such as sensory impairment and varying levels of cognitive ability. The care planning process is fragmented with documents held in various files. The practice of keeping separate files is not good practice and may compromise care delivery. A single care file with care plans and associated documentation ensures that all relevant information is available in one place and provides a comprehensive record of care delivered by all members of the multi-disciplinary team. It is strongly recommended that existing records be consolidated into individual care files. Abbeydale Nursing and Residential Care Home DS0000067386.V288884.R01.S.doc Version 5.2 Page 10 The lack of records relating to the period prior to January 2006 was a concern raised by the Liverpool contract monitoring service. Whilst it is necessary to keep working care files to a workable size many of the documents required in a care file can be used for long periods of time. It is not good practice to rewrite complete records as this breaks the quality assurance cycle of assessment, implementation, evaluation, and re-assessment. When documents are removed to make room within the file they should not be archived but kept in an appropriate storage facility were they can easily be retrieved. The promotion of independence invariably involves an element of risk, which is managed via the completion of relevant risk assessments. Care files examined showed appropriate risk assessments were in place but these were at times contradictory to evidence seen in daily reports and other associated documents. One manual handling risk assessment seen showed the resident as ‘walking independently’ whilst another part of the assessment stated ‘chair bound’. Other risk assessments examined showed errors of omission, inappropriate completion in pencil and obviously incorrect assessments. Consent forms for the use of bed rails were seen but no risk assessments had been carried out before consent had been sought or the bed rails put into use. Daily report sheets were completed in variable amounts of detail. Some members of staff record a good level of detail whilst others record non-specific comments such as “quiet night, all care given”, “No change in condition”, and “good day, all care given”. Statements such as these give no indication as to the actual care delivered, the outcome of that care or how the resident has spent the day or night. Care plans seen were poor and did not reflect all the care required e.g. residents with weight loss but no care plan in place for nutrition. Residents diagnosed with dementia had no care plans in place to address their cognitive impairment, mood management or challenging behaviour. Wound records for two residents had not been updated since 10th May and 25th May. Documentation in two care files showed that a continuing loss of weight had been recorded, but no appropriate changes to care had been made nor had any referrals been made for specialist advice from available services e.g. dietician. The regular evaluation of care plans is essential to monitor the effectiveness of the care delivered. Care plans examined had been reviewed at regular monthly intervals but the evaluation consisted of a date and signature only. The evaluation and review of any care plan must give an indication of the effectiveness or otherwise of the care delivered in accordance with the plan. This evaluation is the justification for the consequent judgement as to whether the care plan is to remain unchanged or modified. Abbeydale Nursing and Residential Care Home DS0000067386.V288884.R01.S.doc Version 5.2 Page 11 Medication administration was not in accordance with current regulations and best practice guidelines. All medications have to be signed for following administration and numerous gaps were seen on the medication administration record (MAR) sheets. The use of labels on MAR sheets was extensive. The use of labels on MAR sheets is not best practice as per the guidelines issued by the Royal Pharmaceutical Society ‘Administration of Medication in Care Homes’. The risk of a label being placed over an existing script is high and this practice should be discontinued. One resident was prescribed an anti-biotic in liquid form with a dose of 20mls twice a day = 40 mls per day. The MAR sheet showed receipt of 100 mls and signatures for the administration of 240mls. The conclusion is that either the receipt for 100mls was incorrect or the incorrect dose was given. Another resident was prescribed Haloperidol capsules which were clearly marked as having been refused. However all of the capsules were still in the relevant blister pack. It is difficult to see how the medication was refused if it had not been taken out of the pack. Eye drops in use were found to be out of date. Temperatures of the drug fridge were recorded on a daily basis but the recordings showed daily min and max temperatures of 3 and 24 accordingly. There is clearly a fault in either the fridge or the thermometer and appropriate remedial action must be taken. The clinic room on the day of inspection was very hot in excess of 25 degrees Celcius. Temperatures of the room should be recorded on a daily basis to ensure that the room temperature does not exceed the optimum temperature range for storage of drugs. Storage above the level of 25 degrees is contary to the manufacturers directions and can compromise the efficacy of the medications stored. Blood glucose tests were performed for a number of residents. Residents did not have individual blood glucose meters as recommended in current guidance, and had tests performed on a single meter. Disposal of unwanted drugs was via an approved special waste contract in accordance with current regulations. Abbeydale Nursing and Residential Care Home DS0000067386.V288884.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): 12,13,14,15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. As far as possible residents have choice and flexibility in how they spend their day in the home, and participate in leisure and recreational activities according to their choice and preferences thereby promoting independence and individuality for each resident. Meals at Abbeydale are good, offering choice and variety whilst catering for residents’ dietary needs or cultural preferences EVIDENCE: The home employs an activities co-ordinator for a variable number of hours per week but is not full time. Activities tend to be group based and include bingo, movement to music, arts and crafts, aromatherapy and outings to local pubs, church and theatre. The co-ordinator was taking a group of residents to the pub on the day of this site visit and this demonstrates that links with the community are well facilitated. The activities person also ensures that residents’ birthdays are celebrated with a party and an appropriate present. The home also provides a range of therapeutic techniques such as aromatherapy and massage. Whilst these activities are clearly only used by qualified therapists as detailed in the service users guide the home must obtain Abbeydale Nursing and Residential Care Home DS0000067386.V288884.R01.S.doc Version 5.2 Page 13 the written consent of the GP before using any technique which has the potential to effect the health and wellbeing of the resident e.g. the use of aromatherapy oils can have an adverse effect on some people. There is a need to review the activities provided particularly in relation to targeting individual preferences and participation. Many of the residents are unable or unwilling for a variety of reasons to participate in-group activities and provision for one to one social recreation and activity is particularly important for those residents with impaired cognitive ability. The identification of likes and dislikes via appropriate assessments (see health & personal care section) together with relevant recording of participation would enable an individually tailored and fully inclusive activity programme to be established. As far as possible residents have choice and flexibility in how they spend their day in the home. Daily routines are kept as flexible as possible and every opportunity for making decisions and exercising choice in many aspects of daily life is positively encouraged. Whilst choice is limited for many of the residents assessed as having impaired cognitive ability staff were observed encouraging and assisting residents to make decisions. Two of the residents have external advocates from a local Pensioners advocacy service. Meals at Abbeydale are varied and provide a balanced diet. Meals seen during the visit were well presented and staff were observed offering assistance when required in a sensitive and dignified manner. Abbeydale Nursing and Residential Care Home DS0000067386.V288884.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): 16,18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents and their families may be certain that complaints are taken seriously and will be acted upon and that residents are protected from abuse. EVIDENCE: There have been two complaints made to the home and one direct to the CSCI since the home passed into new ownership on 1st April 2006. All the complaints made have been substantiated. The complaints register showed no complaints logged and the contractmonitoring visit also looked at the complaints log and confirmed that there had been no complaints since January 2006. Following enquiries the inspector was given the correspondence relating to a complaint made in April. It is clear that this complaint was dealt with in timely and effective manner. However, the complaint resulted as a failure of a piece of equipment, which placed a resident at serious risk of harm. This should have been notified to the CSCI as an event that affected the health, safety or welfare of residents as required under the regulations and this omission is a serious concern. It is strongly recommended that a complaints register be established and that all complaints are recorded together with details of actions taken and outcome. Examination of the training records showed that 63 of staff had received training in adult abuse, its types and recognition together with the procedures Abbeydale Nursing and Residential Care Home DS0000067386.V288884.R01.S.doc Version 5.2 Page 15 to follow if abuse suspected or alleged. Members of staff interviewed were able to demonstrate a good knowledge of adult abuse and its recognition. It is important that all staff including ancillary receive training in adult abuse and this training should be extended to include all staff as soon as possible. Abbeydale Nursing and Residential Care Home DS0000067386.V288884.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): 19,20,22,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The environment at Abbeydale presents as homely and safe but would benefit from a programme of redecoration and refurbishment. EVIDENCE: A tour of the home was conducted accompanied by the acting manager. The laundry was clean and tidy. The fluff filter in the dryer had not been cleaned and there was a significant build-up. The acting manager was not aware of need for daily cleaning and undertook to ensure that it was done in future. There was a badly ripped chair in the lounge diner and other chairs were not as clean as they could be. The carpet was badly stained and requires deep cleaning or replacement. Bathroom 1 had no toilet roll holder or toilet roll, a damaged toilet seat and there was no lid or liner on the bin. Abbeydale Nursing and Residential Care Home DS0000067386.V288884.R01.S.doc Version 5.2 Page 17 Two sluices and the hairdressers’ room were to be open giving easy access to residents. Three rooms had a single bed rail in use and no protective covers A kettle being used by a resident in their room was badly damaged and posed a serious risk, which was removed by the acting manager who stated that the home would replace it. The use of the kettle by the resident had not been risk assessed. The kitchen was clean and well organised. A small amount of chipped crockery was seen which should be disposed of. Two resident toilets and the staff toilet had no toilet rolls in place Room 31 was found to be very malodorous. The use of single bed rails is not acceptable and the residents who have only one bed rail in fitted must have two fitted to the bed. The use of bed rails without protective bumpers in situ is not acceptable. The risks associated with using bed rails without protective bumpers cannot be over-estimated and bumpers must always be fitted. The designated competent person must keep records to evidence regular safety checks on all bed-rails in use. Some of the chairs seen being used in the lounges were unsuitable for the residents using them and the home should review the provision of chairs in relation to height and posture. Abbeydale Nursing and Residential Care Home DS0000067386.V288884.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): 27,28,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff members are deployed in sufficient numbers to meet the residents’ needs. Residents’ are supported and protected by the homes recruitment policies but health, safety and welfare is not always promoted by lack of appropriate training. EVIDENCE: Levels for both trained and untrained members of staff appear sufficient to meet residents’ needs at all times. The care and support required by a resident with dementia increases over the course of a day with a peak usually in the early evening. Given that 50 of the current residents have been assessed as having dementia the reduction of staff from 2pm does not appear to reflect the known dependency and it is recommended that the staffing level for this period be reviewed. The homes training records show that 7 members of the care staff have NVQ 2 and 6 have NVQ 3. This equates to 50 of the total care staff. A further 2 staff members are currently working toward NVQ 2 and 3 towards NVQ 3. On completion this would give 69 of care staff having a relevant NVQ qualification and this is commendable. The staff records have not been updated and the majority of the staff was appointed prior to the new owners taking over the home. There is a need to carry out a comprehensive audit of all personnel files be carried out. This Abbeydale Nursing and Residential Care Home DS0000067386.V288884.R01.S.doc Version 5.2 Page 19 would allow for the records to be brought up to date and make certain that all required and other relevant documents were present. Examination of the records shows that training in the mandatory area is ongoing with: 84 trained in manual handling 63 trained in health & safety 66 trained in infection control 71 trained in fire awareness and prevention 78 trained in food handling and hygiene Induction and foundation in care is not in accordance with the Skills for Care standards. Staff interviewed referred to induction periods ranging from one hour to two days. There was no evidence of training in specialist areas such as diabetes and dementia. It is essential for staff to receive appropriate training relevant to the work they are to perform. Abbeydale Nursing and Residential Care Home DS0000067386.V288884.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): 31,33,35,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home does not currently have a registered manager and the acting manager is currently providing the leadership and guidance required to promote and protect the health, safety and welfare of residents. EVIDENCE: The acting manager was previously the deputy manager before the previous manager left the home. Although relatively inexperienced the acting manager has been accepted in her new role by the residents and staff. It will be a requirement of this report that a permanent manager be appointed and application made for registration with the CSCI. The new management at Abbeydale have a comprehensive quality policy that encompasses all aspects of care at the home. This clearly provides for the enablement and empowerment of residents and their advocates to have input Abbeydale Nursing and Residential Care Home DS0000067386.V288884.R01.S.doc Version 5.2 Page 21 into the services provided at the home and to be involved in any decisions in respect of the resident. It will take a period of time for the mechanisms required to fulfil this policy to be put into place. The records relating to management of residents financial interests need to provide more information than at present. It is a requirement that balances are available to be checked at any time by a person authorised to do so. Monies held in a bank account must be in an account separate from the trading and business accounts. Such account(s) must be interest bearing and appropriate amounts of interest allocated to each resident on a regular basis. Fire safety checks are carried out regularly and recorded and a fire risk assessment was seen. Relevant maintenance contracts, checks and safety certificates were seen for: Fire alarm system Fire extinguishers Portable Appliance checks Electrical installation Emergency lighting system Gas safety certificate Passenger lift Hoists All certificates seen were in date and valid Abbeydale Nursing and Residential Care Home DS0000067386.V288884.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 2 X 2 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X X 2 X X X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 2 X X 3 Abbeydale Nursing and Residential Care Home DS0000067386.V288884.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 OP1 Regulation 4 Requirement The registered person shall ensure that the statement of Purpose is updated to reflect up to date information (refer specifically to management arrangements) Timescale for action 31/07/06 2 OP1 5 (1)(2) 3 OP3 14(1)(a)(c) 4 OP7 15(1) The registered person shall 31/07/06 ensure that the service users guide is updated to reflect up to date information (refer specifically to management arrangements) and shall supply a copy of the service user’s guide to each service user The registered person shall 31/07/06 ensure that the needs of the service user have been assessed by a suitably qualified or suitably trained person and that there has been appropriate consultation regarding the assessment with the service user or a representative of the service user The registered person shall, after 31/08/06 consultation with the service user, or a representative of his, prepare a written plan as to how the service user’s needs in DS0000067386.V288884.R01.S.doc Version 5.2 Page 24 Abbeydale Nursing and Residential Care Home respect of his health and welfare are to be met. 5 OP8 12(1) The registered person shall ensure that the care home is conducted so as (a) to promote and make proper provision for the health and welfare of service users; (b) to make proper provision for the care and, where appropriate, treatment, education and supervision of service users The registered person must ensure that medication policies and procedures be reviewed in line with Royal Pharmaceutical Society of Great Britain and Nursing & Midwifery Council guidelines to cover all aspects of medicines management. 31/07/06 6 OP9 13(2) 31/07/06 7 OP12 16(2)(n) 8 OP16 17(2) The registered person shall 31/08/06 having regard to the size of the care home and the number and needs of service users – consult service users about the programme of activities arranged by or on behalf of the care home, and provide facilities for recreation including, having regard to the needs of service users, activities in relation to recreation, fitness and training The registered person shall 31/07/06 maintain in the care home the records specified in schedule 4 specifically item 11 – a record of all complaints made by service users or representatives or relatives of service users or by persons working at the care home about the operation of the care home, and the action taken DS0000067386.V288884.R01.S.doc Version 5.2 Page 25 Abbeydale Nursing and Residential Care Home 9 OP19 23(d) 10 OP22 23(2)(n) 11 OP26 16(2)(k) 12 OP29 19 13 OP30 18(1)(c) by the registered person in respect of any such complaint The registered person shall having regard to the number and needs of the service users ensure that all parts of the care home are kept clean and tidy The registered person shall having regard to the number and needs of the service users ensure that support, equipment and facilities as may be required are provided, for service users who are old, infirm or physically disabled. (Refer to chairs) The registered person shall having regard to the size of the care home and the number and needs of service users keep the care home free from offensive odours. The registered person must obtain all the documents and records for all persons employed as specified in paragraphs 1 to 7 of Schedule 2 of Regulation 19 of the The Care Homes Regulations 2001. The registered person shall having regard to the size of the care home, the statement of purpose and the number and needs of service users - ensure that the persons employed by the registered person to work at the care home receive training appropriate to the work they are to perform (refer to induction and foundation training) The registered person shall appoint a suitably qualified and experienced person to manage the care home The registered person shall establish and maintain a system for reviewing at appropriate intervals and improving the DS0000067386.V288884.R01.S.doc 31/07/06 31/07/06 31/07/06 31/08/06 31/07/06 14 OP31 9 30/09/06 15 OP33 24(10 31/07/06 Abbeydale Nursing and Residential Care Home Version 5.2 Page 26 16 OP35 20(1)(a)(b) 17 OP38 37(1)(c) 18 OP38 13(4) quality of care provided at the care home including the quality of nursing where nursing is provided at the care home. The registered person shall not 31/07/06 pay money belonging to any service user into a bank account unless: a) the account is in the name of the service user, or any of the service users, to which the money belongs b) the account is not used by the registered person in connection with the carrying on or management of the care home The registered person shall give 31/07/06 notice to the Commission without delay of the occurrence of any serious injury to a service user The registered person shall make 31/07/06 suitable arrangements for the training of staff in first aid RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP7 OP18 Good Practice Recommendations It is strongly recommended that all existing care records be consolidated into individual care files to provide a comprehensive record of care delivery. It is strongly recommended that the training in abuse and its recognition be extended to all members of staff irrespective of the area in which they work Abbeydale Nursing and Residential Care Home DS0000067386.V288884.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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 Nursing and Residential Care Home DS0000067386.V288884.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. 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