Inspection on 02/01/07 for Abbeydale Nursing and Residential Care Home

This inspection was carried out on 2nd January 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 Nursing and... 02/10/07

Abbeydale Nursing and... 12/06/06

Similar services:

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 2nd January 2007 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.V327979.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.V327979.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 0151 298 2218 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) Doson Limited Care Home 36 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.V327979.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. 12th June 2006 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 to 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.V327979.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit took place over a period of eight hours. During the visit care records and associated documents, staff files and management records were examined. A number of staff, relatives and residents were spoken to during the course of this visit to obtain their views in respect of the care and service provided at the home. Both staff and relatives spoken to were clear in their view that the home had improved and was continuing to do so. All residents appeared well cared for and staff were observed delivering care in a sensitive and respectful manner. Significant investment has been made in improving the environment, training and provision of activities and social recreation and is ongoing. Serious concerns however in relation to care management have been identified with medication management and care records being areas that must be addressed as a priority. 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. The summary of this inspection report can be made available in other formats on request. Abbeydale Nursing and Residential Care Home DS0000067386.V327979.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.V327979.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 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: Abbeydale has a Statement of Purpose and Service User Guide. Both documents are well presented and easy to read and contain the required information. Recent changes in the management of the home need to be reflected in the documents and it is recommended that following revision that the Service users Guide is distributed to the residents or their representatives to ensure that they have up to date information. Examination of files showed that appropriate contracts or Statement of Terms and Conditions are issued and copies kept on file. Abbeydale Nursing and Residential Care Home DS0000067386.V327979.R01.S.doc Version 5.2 Page 8 Pre-admission assessments seen were lacking information in appropriate detail and did not accurately reflect the needs of the resident. The use of a structured and comprehensive pre-admission assessment document would greatly enhance both the quality and quality of information obtained and provide reassurance to the prospective resident or their representative that their needs can be met. The home is equipped with a range of facilities to meet residents’ needs including a passenger lift, handrails, assisted bathrooms and handrails. A programme of training has been commenced that is addressing the shortfall in training and completion will promote the homes capacity to meet residents’ assessed needs. 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. Abbeydale is not registered for intermediate care. Abbeydale Nursing and Residential Care Home DS0000067386.V327979.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ health needs are not being met due to a lack of clear direction in care plans and a failure to manage medications in accordance with the homes policies and procedures which places residents at risk of harm or injury. EVIDENCE: Examination of care plans showed that the structure and format of the care files has been changed since the previous visit. The care planning process is neither comprehensive nor consistent and provides no direction in respect of care required. The format and structure of care plans must be revised to allow for the inclusion of discrete problems or activities of daily living and the interventions required to meet the assessed needs. The overall standard of regular care plan review was poor. The use of comments such as ‘continue with present care plan’ or ‘care plan still in progress’ give no indication as to whether the care plan is effective. The Abbeydale Nursing and Residential Care Home DS0000067386.V327979.R01.S.doc Version 5.2 Page 10 regular evaluation of care plans is essential to monitor the effectiveness of the care delivered and therefore the evaluation must detail the effectiveness or otherwise of care delivered thereby justifying any changes or no change to the plan. The promotion of independence invariably involves an element of risk, which is managed via the completion of relevant risk assessments. The required risk assessments were not always present in the care files examined. One care file had no nutritional assessment in place. Another file showed an appropriate risk assessment for the use of bed rails but was clearly inaccurate as the height of the mattress was said to compromise safety but extra high bed rails were assessed as not being required. Additionally, neither the resident nor their representative had signed the agreement for use of bed rails. Where risk assessments were present and reviewed, examination showed that the assessments were not always accurate and any reviews did not always reflect changes, which were evidenced in other parts of the care file. Associated documentation such as fluid intake charts, repositioning charts, investigations done with relevant results and regular observations are poorly maintained and do not demonstrate the level of care given. The associated care documentation provides the evidence that relevant care interventions have been carried out, the effectiveness of care delivery and ongoing progress or otherwise and accurate record keeping is essential. Examination of wound management records showed that information was not always present in the care file. Full mapping of wounds or sores must be undertaken so that improvements or deteriorations can be identified in the early stages to further plan the treatment to be given. The details of prescribed dressings must be clear and reasons for any variation recorded. Daily reports seen were completed to a good level of detail giving a good indication of the care delivered. A specialist pharmacy inspector reviewed medication management. There were serious concerns surrounding the handling, administration and recording of medication within this service. Staff spoken to showed a lack of understanding of systems for the correct ordering and administration of medication. There was little or no evidence that nurses administered and recorded medication in line with the Nursing and Midwifery Council code of ethics and current guidelines. This meant that not all residents received their medication as prescribed and their health and wellbeing was at serious risk of harm. Policies and procedures were available, however it was recommended that they be reviewed. It was also recommended that a Homely Remedy policy should be written and implemented. This would ensure that residents were not given Paracetamol etc that had been prescribed for another resident. Staff confirmed Abbeydale Nursing and Residential Care Home DS0000067386.V327979.R01.S.doc Version 5.2 Page 11 that if a resident needed Paracetamol, and they had none of their own, then supplies would be taken from another resident. This practice is illegal and must stop. All staff must be aware of, and abide by the homes policies and procedures in order to protect the health and wellbeing of residents. An audit of current stocks and records showed that some residents had not received enough medication whilst other medication was missing and could not be accounted for. Some medication had been signed for as administered on the Medication Administration Record charts (MARs) but stock levels showed that it had not been given. Stock balances were not always transferred accurately onto the new MARs and there were no records of the destruction of medication that had been refused. In one example, 2 boxes of medication had been received, but the balance brought forward onto the following MARs only referred to the contents of 1 box. When the last tablet in the box had been given, the nurse had recorded on the resident’s MARs that the item was ‘finished’ even though there was another box still in stock. The note implied that the doctor had stopped this medication when this was not the case. Residents’ health and wellbeing is at risk if accurate records are not kept. Medication must not be signed for unless it has been administered. Nurses must ensure that records are kept in line with the Nursing and Midwifery Council guidelines. Residents who had recently had medication changes made by dieticians, General Practitioners or hospital staff were at particular risk, as these changes had not always been transferred from the old Medication Administration Record charts (MARs) to the new ones. The handwritten entries on MARs had not been double signed and were sometimes incomplete and occasionally sticky labels had been used on MARs. Nurses spoken to demonstrate an alarming lack of knowledge with regard to dealing with medication changes and ensuring that residents had supplies of all current medication. E.g. one resident’s hospital discharge letter showed that the brand of one tablet had been changed and a new tablet added. This resident was now receiving both the old and the new brand of the same medication, whilst the new tablet had not been given since the supply issued by the hospital had run out. The discharge letter clearly indicated that the new medication was to be continued and was not a course, however the resident’s MARs had been marked ‘course finished’. This meant that this resident had not received the correct treatment for over a month. Another resident had not received the correct nutritional supplements for over a month, despite clear guidance from the dietician. In five cases it was not possible to confirm information on the MARs with other records held in the home. Residents’ health and wellbeing is at risk if medication is stopped or withheld without authorisation from the prescriber. Medication must be administered as Abbeydale Nursing and Residential Care Home DS0000067386.V327979.R01.S.doc Version 5.2 Page 12 prescribed at all times. When medication is not given, then the clinical reason for this should be recorded. Nurses did not always have enough information to administer medication safely. E.g. one resident was prescribed a sedative ‘to be given when required for agitation’. There was no further information explaining how to tell when the resident needed it, or how often it should be given or how much to give. Records showed that it was normally offered twice daily. Staff confirmed that it was generally refused in the morning, but given at night to stop the resident from wandering around the home. The morning dose was not recorded as being offered again later. This resident is at risk of being given the medication in order to control undesirable behaviour rather than for the reason it was intended. Such practice could lead to medication abuse. One resident’s medication was administered via a PEG (feeding) tube. Written authority from the General Practitioner for this procedure was not available. Detailed instructions for carrying out this procedure could not be found. There was no system in place to monitor and review the quality of medicines management within the home. This meant that checks were not made to ensure residents had received their medication correctly and that nurses were maintaining good practice. This meant that medication errors went undiscovered, practice was poor and no action was taken to improve the quality of this vital area of care. Given the serious shortfalls in this area, it was required that nurses undergo further training in all aspects of medicines management. Staff must only be allowed to administer medication when they have been assessed as competent to do so. The delivery of care was observed throughout the course of this visit. Care staff was seen to address and treat residents with respect and privacy was maintained whilst personal care was carried out. Abbeydale has appropriate policies and procedures in place to promote the treatment of residents and their families with sensitivity and respect at he end of life. Abbeydale Nursing and Residential Care Home DS0000067386.V327979.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. 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 and appropriate leisure and recreational activities promote wellbeing for each resident. EVIDENCE: The home has employed an activities co-ordinator for 5 hours per day who had been in post for two weeks at the time of this visit. The co-ordinator is qualified and experienced and has set out an initial programme for January which includes one to one sessions to promote individual hobbies and interests as well as life story writing. Other activities include reminiscence, board games, crafts and musical bingo. A high priority is being given to individual requirements taking into account previous interests and hobbies and an example of this is the provision of regular trips for one service user to purchase magazines relevant t their previous occupation. It s intended to utilise the ‘Windows to a wider world theory’ by promoting links with local companies and organisations that are relevant to the service users previous lifestyles. Plans are in hand for the involvement were possible for residents to attend events such as tea dances, the tall ships visit in June and other events in the community such as Liverpool’s 800th birthday celebrations. Abbeydale Nursing and Residential Care Home DS0000067386.V327979.R01.S.doc Version 5.2 Page 14 Work has commenced on the creation of a sensory room in an unused lounge will provide a calming non-energetic atmosphere with various levels of stimuli for all. The home has a policy of open visiting with friends and family welcome at any reasonable time and to stay as long as they and the resident wished. Visitors were observed to be arriving at the home throughout the day and residents were able to see their guests in one of the communal areas or in their own rooms as they wished. Daily routines are kept as flexible as possible in order to maximise individual choice and autonomy. Relatives spoken to were complimentary about the assistance their dependents received from the staff in relation to their personal choice, which was encouraged in many aspects of the daily routines. Typical comments from relatives were ’although mum does not respond much now she is always encouraged to make her own decisions e.g. she is always asked if she wants to go for a rest after lunch and never just taken without asking’, ’sometimes decides to have a lie-in and has breakfast in bed’. Dietary needs are well met both in terms of quantity and quality. Meals seen were well presented with staff members available to assist in a sensitive and discrete way if required. Abbeydale Nursing and Residential Care Home DS0000067386.V327979.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): 16,17,18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents and their representatives can be certain that complaints are taken seriously and that residents are protected from abuse EVIDENCE: There have been no complaints to the home or directly to the CSCI since the previous visit. The home maintains a record of all complaints that includes details of any investigations carried out and the outcome. It is recommended that a record be kept of any verbal complaints made together with details of actions taken in order to promote openness and transparency. The manager confirmed that all residents are registered on the electoral roll and assistance would be given if required to enable residents to exercise their vote in any elections. Training records examined showed that 47 of staff has received training in adult abuse, its types and recognition together with the procedures to follow if abuse is suspected or alleged. Staff members who have not as yet received this training are scheduled to attend relevant training sessions by the end of March 2007 Abbeydale Nursing and Residential Care Home DS0000067386.V327979.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Ongoing investment is improving the environment promoting a safe, homely and comfortable environment for residents. EVIDENCE: A tour of the home was undertaken accompanied by the manager. The home appears well maintained and shows clear evidence of an ongoing decoration and refurbishment programme. Residents’ rooms are well furnished, bright and spacious with many rooms personalised by residents’ with personal possessions and memorabilia. The dining room furniture has all been renewed together with carpet and flooring and a new assisted bath has been installed. The majority of easy chairs in the lounge have been replaced with a number of recliner chairs for residents’ comfort. The manager stated that 15 sets of new bedroom furniture Abbeydale Nursing and Residential Care Home DS0000067386.V327979.R01.S.doc Version 5.2 Page 17 have been ordered. The lack of outstanding minor repairs demonstrates a good level of maintenance. There are sufficient numbers of suitable toilet and washing facilities for residents. A number of the toilets have permanently floor fixed handrails in place. The cross bar on two of these fixed handrails have become rusted and present a hazard to residents and need repair if possible or replacement. The use of such permanently fixed aids limits the use of other aids such as raised toilet seats and it is recommended that consideration be given to replacing them with wall mounted moveable grab rails which would allow the use of other aids if required. The laundry was clean and tidy but relevant COSHH documents were not available and it is strongly recommended that copies of the relevant documents be provided for the laundry staff. On the day of this visit the home was clean, tidy and odour free. Abbeydale Nursing and Residential Care Home DS0000067386.V327979.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. 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 are recruited via robust procedures and deployed in sufficient numbers and skill mix to promote and support residents’ health, safety and welfare. EVIDENCE: Examination of the off-duty rosters showed sufficient numbers of care staff throughout the day and night to meet the residents’ needs. The home has 62.5 of care staff qualified to at least NVQ level 2 with six staff members having attained NVQ level 3. A further six members of staff are currently working towards the qualification which would achieve a 100 qualified care workforce. Policies and procedures are in place to promote a robust recruitment. Personnel files examined showed that all appropriate information and documents is obtained. Significant progress has been made in relation to training, which for all staff is now ongoing. Examination of the training records shows that training has been given in specialist areas such as dementia care and challenging behaviour. Assurances were given by the manager that training in the mandatory areas of would be completed by the end of March 2007. Abbeydale Nursing and Residential Care Home DS0000067386.V327979.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,37,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The general management and administration at Abbeydale has improved and is focussed on the promotion of the health, safety and welfare of residents. EVIDENCE: The new manager at Abbeydale was registered by the CSCI in November 2006. A second level nurse Ms Champness-Smith holds the registered managers award and the NVQ level 5 Diploma in Management. The senior nurse who has taken on the role of clinical lead supports the manager. Since her appointment the manager has reviewed all aspects of the service provided and has made significant improvements in the general management of the home. Ms Champness-Smith has an open and transparent management Abbeydale Nursing and Residential Care Home DS0000067386.V327979.R01.S.doc Version 5.2 Page 20 style with a clear sense of direction and strategies to promote and enable an inclusive way forward for staff, residents and their representatives. As previously stated in earlier sections of this report serious concerns have been identified in relation to the care management at Abbeydale and substantial improvement is required particularly in respect of care planning, record keeping and medication management. The home has comprehensive policies and procedures in place but there is no formal quality assurance in place at present. Documents seen showed that the appropriate protocols are almost complete and a system of continuous quality assurance will be in place in the very near future. The records relating to the management of residents monies are much improved and a bank account has been opened that is separate from the business account to hold residents funds. The provider has experienced difficulties with the relevant authorities in completing the transfer of authorities for residents’ monies but assurances have been given that this will be completed by the end of February. The provider has ensured that residents have not been penalised and has funded all expenditure on residents’ behalf until the relevant funds are available. The manager has put a system of formal staff supervision in place, which is carried out at least six times per year. Records in respect of the general management of the home are up to date and all records are kept securely in accordance with the Data Protection Act. Residents’ rights and best interests are not safeguarded by the poor standard of care management records and this must be addressed urgently. Fire alarm and emergency lighting checks are carried out on a regular basis and an up to date fire risk assessment was seen. Relevant maintenance contracts, checks and inspection certificates were seen for: Fire alarm system Fire extinguishers Portable appliance checks Electrical installation Emergency lighting system Gas safety certificate Passenger lift Assisted baths and hoists Abbeydale Nursing and Residential Care Home DS0000067386.V327979.R01.S.doc Version 5.2 Page 21 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 2 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 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 3 18 3 2 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 X 2 3 2 3 Abbeydale Nursing and Residential Care Home DS0000067386.V327979.R01.S.doc Version 5.2 Page 22 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. Timescale for action 31/03/07 2. OP1 5 (1)(2) The registered person shall 31/03/07 ensure that the service users guide is updated to reflect up to date information and shall supply a copy of the service user’s guide to each service user. The registered person shall 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 and that assessments are appropriately documented 31/03/07 3. OP3 14(1)(a)(c) 4. OP7 15(1) The registered person shall, after 30/04/07 consultation with the service user, or a representative of his, prepare a written plan as to how the service user’s needs in DS0000067386.V327979.R01.S.doc Version 5.2 Page 23 Abbeydale Nursing and Residential Care Home respect of his health and welfare are to be met that details and gives clear directions in respect of the interventions and care required. 5. OP8 12(1) The registered person shall ensure that the care home is conducted so as to promote and make proper provision for the health and welfare of service users; 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. The registered person must ensure that full and accurate records are kept of all medicines received, administered and leaving the care of the home. The registered person must ensure that there is a full record of all medication, nutritional supplements, dressings and other items currently prescribed for each resident. Adequate stocks of these items must be kept at all times. The registered person must ensure that all medication is only administered in accordance with the General Practitioners instructions The registered person must DS0000067386.V327979.R01.S.doc 28/02/07 6. OP9 13(2) 31/01/07 7 OP9 13(2) Sch. 3(i) 31/01/07 8 OP9 13(2) 31/01/07 9 OP9 13(2) 31/01/07 10 OP9 13(2) 31/01/07 Version 5.2 Page 24 Abbeydale Nursing and Residential Care Home ensure that medicines are only administered to the resident for whom they were prescribed. 11 OP9 13(2) The registered person must ensure that staff authorised to administer medication receive appropriate medicines management training and have an assessment of their competence, prior to performing these tasks. The registered person shall ensure that all parts of the home to which service users have access are free from hazards to their safety (refer specifically to rusty fixed handrails in toilets) The registered person shall establish and maintain a system for reviewing at appropriate intervals and improving the quality of care provided at the care home including the quality of nursing where nursing is provided at the care home. 31/03/07 12 OP22 13(4)(a) 31/03/07 13 OP33 24(10 30/04/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Abbeydale Nursing and Residential Care Home DS0000067386.V327979.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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 Nursing and Residential Care Home DS0000067386.V327979.R01.S.doc Version 5.2 Page 26 - 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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