Inspection on 14/02/07 for Abbeydale Nursing Home

This inspection was carried out on 14th February 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 Home 08/01/09

Abbeydale Nursing Home 01/02/08

Abbeydale Nursing Home 31/07/07

Abbeydale Nursing Home 26/04/06

Abbeydale Nursing Home 21/10/05

Abbeydale Nursing Home 02/06/05

Abbeydale Nursing Home 13/10/04

Abbeydale Nursing Home 13/05/04

Abbeydale Nursing Home 02/12/03

Abbeydale Nursing Home 05/09/03

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Abbeydale Nursing Home 88 Handsworth Wood Road Handsworth Wood Birmingham West Midlands B20 2PL Lead Inspector Ann Farrell Key Unannounced Inspection 14th February 2007 08:00 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 Home DS0000024813.V328646.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 Home DS0000024813.V328646.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbeydale Nursing Home Address 88 Handsworth Wood Road Handsworth Wood Birmingham West Midlands B20 2PL 0121 554 5024 0121 523 6001 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) Mr Jitendra Patel Mrs Ifeoma Cecilia Ezeani Care Home 35 Category(ies) of Dementia - over 65 years of age (35), Old age, registration, with number not falling within any other category (35) of places Abbeydale Nursing Home DS0000024813.V328646.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. A maximum of 32 service users may reside in the home for the duration of the temporary measures, or until such time as any permanent additions have been approved and constructed. That three named service users can be accommodated in the home who are under 65 years of age. 26th April 2006 2. Date of last inspection Brief Description of the Service: Abbeydale Nursing Home is a period house that has been adapted and extended with a two-storey extension to create a home offering nursing care for up to 35 older people. Currently the home can only accommodate 32 residents. The home is situated in a residential area of Birmingham. The railway station is nearby and the home is on a bus route. There is one main lounge on the ground floor plus two further small lounges and a dining room. There are sixteen single bedrooms plus eight double bedrooms and seven have en-suite facilities. However all en-suite facilities are not suitable for residents with mobility problems. A passenger lift gives access to all floors. To the rear of the building where laundering of all linen and clothing is undertaken and the kitchen is situated on the ground floor. A large garden is situated to the rear of the home. The area at the front of the home is made over largely for car parking, which is limited and contains well established herbaceous and shrub borders. The home accepts residents from a wide variety of cultural and ethnic backgrounds. Abbeydale Nursing Home DS0000024813.V328646.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The fieldwork inspection was conducted over two days commencing at 8am on 14th February. The manager was present for the duration of the inspection. During the fieldwork the manager, eight members of staff three relatives and six residents were spoken to. The feedback from relatives was good; they found the staff helpful and welcoming. Residents were generally satisfied although issues were brought up in respect of some staff who were clumsy/abrupt, the food was cold at times and choices were not always available. There has been an improvement in the arrangements for activities and some decorating, but many requirements remain outstanding in respect of the environment. During the inspection process the inspectors toured the home, sampled residents files and other documentation. Case tracking was used to determine care for residents from the time of admission to the home plus direct and indirect observation as a number of residents were unable to communicate their views verbally. Information was also utilised from the pre inspection questionnaire, which was provided by the home prior to fieldwork. A random inspection was conducted in September 2006 to follow up on requirements from the previous inspection and at that time a new manager had been employed, re-decoration had commenced and some new lounge chairs had been purchased. A further random visit was undertaken in December 2006 in response to a complaint about medication, recruitment and manual handling practices. A that time it was found that some medication had not been stored correctly, but regulations had been met in other areas. Durign this inspection a complaint was received in respect of residents loosing weight, residents not being fed and food being thrown away. Some residents were observed to be of a low body weight, but there was no evidence of significant weight losses. On the second day of the inspection a referral was made to Social Care and Health, following an allegation of abuse and appropriate action was taken by the manager. What the service does well: On discussion with residents they stated they were happy living in the home. The home admits residents from a range of cultural backgrounds and the cultural mix of residents is also reflected in the staff group. They provide a choice of meals including cultural options, which residents enjoyed and stated they received good portions. Abbeydale Nursing Home DS0000024813.V328646.R01.S.doc Version 5.2 Page 6 A dedicated activity co-ordinator is employed and an external organisation visits regularly to provide movement to music for residents. What has improved since the last inspection? What they could do better: Although there has been some progress many of the requirements remains outstanding from previous inspections. The proprietors will need to take more positive action to address these issues in a timely manner and demonstrate the home is being well managed. The shortfalls in respect of team working and communication needs to be addressed to ensure resident’s needs are met and outcomes are positive by a fully committed and positive staff group. There needs to be a more pro-active approach to prevention of complications to ensure residents health care needs are met. The systems for dealing with concerns and complaints needs to be reviewed and a more pro-active approach taken to ensure residents are adequately protected. The arrangements for resident’s finances needs to be reviewed, records in place and separate bank account must be put in place for money held on Abbeydale Nursing Home DS0000024813.V328646.R01.S.doc Version 5.2 Page 7 behalf of residents to demonstrate residents money is being managed properly. A number of areas in respect of the maintenance and servicing of equipment need to be addressed with some urgency to ensure a safe environment for residents. Re-decoration and re-furbishment schedule must be drawn up with realistic timescales to enhance the surroundings and provide a homely environment for residents. Further improvements in infection control procedures are required with staff training, practice and equipment. The assessment and care planning process needs to be enhanced to ensure resident’s needs are identified and consistently met by staff who are familiar with the agrees plan of care. The quality assurance system needs to be reviewed and developed further and where any issues are identified by residents or stakeholders action must be taken to address them. 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 Home DS0000024813.V328646.R01.S.doc Version 5.2 Page 8 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 Home DS0000024813.V328646.R01.S.doc Version 5.2 Page 9 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): 1,2,3,6 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Information available does not accurately inform prospective residents or their relatives about the services or facilities. There has been some improvement in the admission procedure, but it requires further development to provide confidence to residents that their needs can be met when moving into the home. EVIDENCE: The home generally admits residents who require nursing care for long-term care. There is a service user guide available for prospective residents providing them with information about the facilities and services, which has recently been updated. However, some of the information is not accurate and there was no copy of the terms and conditions of residence, so prospective residents and their relatives would not be able to make an informed choice about moving into the home. Copies of the service user guide were also available in bedrooms, but this was out of date. This will need to be reviewed, Abbeydale Nursing Home DS0000024813.V328646.R01.S.doc Version 5.2 Page 10 updated and copies made available to ensure residents and their relatives receive accurate information about the home to enable them to make an informed choice about moving into the home. There was no evidence of a contract of residence for residents. This area will need to be addressed in order to inform residents and their representatives of the terms and conditions of any stay in the home. A copy of the contract should be retained on the residents file in the home A small sample of resident’s files were inspected to determine the admission process. It was found that a member of staff had completed a pre-admission assessment, but in some cases the document was not comprehensive and were not dated or signed by the member of staff completing the assessment. Without a comprehensive assessment it cannot be guaranteed that the home can meet prospective residents needs. There was no evidence that the manager writes to prospective residents confirming that the home can meet their needs following the pre admission assessment. The home has a number of residents who suffer with cognitive impairment. Previous inspections have identified that training was required in this area in order to provide staff with the knowledge to care for residents with cognitive impairment. It was stated that a training package had been devised, but the training has not been passed down to staff to date. This area needs to be addressed in order to provide staff with the skills and knowledge to care for residents with cognitive impairment. Some of the rooms are small, toilets, en-suite and assisted bathing facilities have limited space and it would be difficult to manoeuvre equipment such as hoists for manual handling. The manager of the home must ensure that when assessing residents for admission to the home these factors are taken into consideration and ensure residents needs can be met by the facilities available. It is recommended that reviews be undertaken in respect of signage and decoration of communal areas of the home in relation to the needs of residents with cognitive impairment. Different rooms and areas should look different so the residents with cognitive impairment have their independence promoted and avoid unnecessary difficulties. The parts of the home with the original Victorian features do look different and unique, however other parts of the building could prove difficult to these residents. Improvements in signage and different colours for various areas and doors are required so that residents can distinguish between them. Abbeydale Nursing Home DS0000024813.V328646.R01.S.doc Version 5.2 Page 11 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Medication systems were of a good standard. There had been some improvements in the care planning systems, but further development is required. A more proactive approach to care with prevention of complications is required to ensure residents health care needs are met. EVIDENCE: There was evidence that following admission to the home resident details and past history was taken along with the completion of risk assessments in respect of tissue viability, nutrition, manual handling, the use of bedrails etc. Some of the risk assessments had not been completed for all residents; therefore some risks may not have been identified. There were no assessments in respect of mental health or continence, where residents had needs in these areas. There was no evidence that the resident or any other significant person such as relatives, G.P. hospital etc. had been involved in the process to provide relevant information about residents needs. A nutritional assessment is undertaken by staff to determine resident’s nutritional status, but there is no objective tool to determine if the body weight was satisfactory Abbeydale Nursing Home DS0000024813.V328646.R01.S.doc Version 5.2 Page 12 such as body mass index. Assessments must be comprehensive so that resident’s needs are identified and suitable action is put in place to meet the needs. Staff draw up a care plan for residents following admission to the home outlining how the resident’s needs are to be met by staff. Records contained vague instructions on how to meet residents individual needs, they were not comprehensive, had not been updated when there were changes in care and some had not been signed or dated by the member of staff drawing them up. There was no indication of involvement of the resident or their representative to include their preferences in the care plan. It was noted that a number of the care plans had been reviewed by the night staff who would not be fully aware of how residents needs were being met during the day. Also when issues had been raised about aspects of care the risk assessments had not been reviewed or care plans updated to reflect the changes. Without comprehensive care plans it cannot be guaranteed that residents needs will be fully met. Care planning needs to be reviewed along with staff training to ensure comprehensive care plans are drawn up and resident’s needs met in a consistent manner. Since the previous inspection arrangements have been made for all residents to be registered with one G.P. who visits the home on a weekly basis and when required. Although this may enable more consistency to residents and the home residents should be offered a choice of G.P. when admitted to the home. Records included separate sheets to indicate visits by the G.P. and other health professionals. There was evidence of visits by the G.P, optician and chiropodist but not of visits by a dentist. The manager must ensure that all residents have the opportunity to see a dentist on a regular basis and ensure it is recorded in their records. The inspectors could not evidence records to demonstrate that residents with chronic diseases such as diabetes; asthma and high blood pressure etc. were receiving regular health checks in order to monitor adequate control and identify and complications. Nurses were checking diabetic residents blood sugar twice a day, but guidance indicates that they should have regular blood tests undertaken. This area will need to be followed up by the manager to ensure resident’s diabetes is monitored effectively. During the inspection it was noted that staff were completing turn charts and fluid charts on a regular basis to demonstrate the care provided. It was noted that some residents who were receiving tube feeds were not propped sufficiently upright when feeding was in progress. All staff should be made aware of the correct positioning of residents when artificial feeding is in progress in order to prevent complications. Following an audit by the tissue viability nurse service the home is in the process of purchasing some new mattresses and chairs, but some further new ones are required in order to meet resident’s needs. Staff liaise with the tissue viability nurse when required, obtain dressings and follow instructions Abbeydale Nursing Home DS0000024813.V328646.R01.S.doc Version 5.2 Page 13 satisfactorily. During the inspection it was found that a residents pressure sore had healed who had been admitted to the home. However, another pressure sore had developed about one month later in the same area and another resident developed a pressure sore when in the home. At the time of inspection it was noted that some slide sheets did not extend the length of resident bodies and this may increase the risk of sores to heels due to friction. This raises concerns about preventative care and staff must take a more proactive approach to ensure prevention of complications such as pressure sores. A complaint was received during the inspection about residents loosing weight, but this could not be evidenced. However, there were some resident with low body weight and there was no evidence in care plans to indicate that action had been taken to address the concern. There will need to be a more proactive approach in this area to ensure the concern is managed appropriately and effectively. At the time of the last inspection a number of wheelchairs had been purchased. It was not clear that residents had been assessed for wheelchairs. All residents should be assessed for their own wheelchair to ensure it is suitable for the individuals needs. Other areas identified during inspection that require attention include: • The alarm to a pressure-relieving mattress was switched off and when it was switched on it alarmed indicating a fault in the system. Also the electrical supply to one pressure relieving mattress had been switched off so it was not inflating properly and this puts residents at more risk of tissue damage. • Staff were using latex gloves for general use. Vinyl gloves should be used routinely to prevent allergies. There were also poor infection control practices, as staff were not removing gloves and aprons when they had finished attending to one resident before moving onto the next one. • Poor manual handling techniques were observed on at least three occasions and staff were observed to be attending to residents on their own when two staff were required. This puts residents and staff at risk of injury. • Records indicated that residents do not have the opportunity of regular baths or showers. This may be linked to the bathing facilities, which are cramped and not suitable for the residents group. • Lemon and glycerine swabs are used for mouth care where residents are unable to eat or drink. However, this is not recommended, as they tend to dry the mouth. Mouth care practice needs to be reviewed. • The records in respect of changing dressings suggest they were not consistently undertaken and this may delay the process of healing. • Some issues such as possible urine infections were not followed up by staff or referred to the G.P. Abbeydale Nursing Home DS0000024813.V328646.R01.S.doc Version 5.2 Page 14 • The home has some residents who do not speak English. Although some staff are able to communicate with them there are shifts when there are no staff on duty who can effectively communicate. This could result in residents needs not being identified and action will need to be taken to address this issue. On discussion with residents they stated they were content and had no complaints. It was stated some staff were very good, but some were clumsy/rough. On discussion with one visitor it was stated their relative was well looked after and she was able to be involved in their care e.g. by feeding them. The home uses a monitored dosage system of medication, which is stored appropriately. On inspection of the medication charts (MAR) the administration and recording was found to be of a good standard. The only area that requires attention is in respect of creams, as some had not been dated when opened. Creams should be dated when opened and discarded after a specific time due to the risk of bacterial contamination. Also it was noted there were no suction catheters in the event of an emergency. There is a telephone in the reception area and a hand held set when privacy is required. Staff were noted to respect residents privacy knocking on doors before entering. Abbeydale Nursing Home DS0000024813.V328646.R01.S.doc Version 5.2 Page 15 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 adequate. This judgement has been made using available evidence including a visit to this service. The meals offered are of a satisfactory standard. Areas in respect of timing of meals, choice and menu planning need to be reviewed. Arrangements for stimulation of residents has improved providing more activities and stimulations for residents. EVIDENCE: Visiting is flexible enabling relatives to visit at a time that suits them and residents to maintain contact with them. Residents are able to bring personal items of furnishings etc into the home in order to personalise their rooms and make them more homely. Since the last key inspection a new member of staff has taken up the post of activities co-ordinator and was very enthusiastic. They have not received specific training and it is recommended that this be considered. The activities co-ordinator is in the process of compiling information about residents with a form called “getting to know you”, which was positive as information about residents past interests and hobbies was being obtained. Activities include celebration of Diwali, Christmas and birthdays plus shopping trips, painting, visiting church. On touring the home there were examples of artwork on the Abbeydale Nursing Home DS0000024813.V328646.R01.S.doc Version 5.2 Page 16 wall in one of the lounges and an album with photographs of a day trip out. Records were lacking in respect of activities undertaken by residents to demonstrate they were adequately stimulated and this area will need to be addressed. At the previous inspection it was stated that residents spent time in the garden during the summer. Although there is access from the building to the garden it is not suitable for residents to use due to lack of suitable paving or walking areas etc. This will need to be addressed before the weather improves so that it can be fully utilised. The home employs separate catering staff who provide three full meals per day. There is a four-week rotating menu, which provides a choice at lunchtime. There is also an Afro Caribbean and Asian option available to meet the needs of residents from minority groups. It was stated that residents were consulted about choices on the day prior to serving the meal, but on discussion with some residents they stated that choices were offered sometimes. On discussion with the catering staff it was stated that the Asian option is rarely taken and the Afro Caribbean option is available twice a week. Records of food demonstrate the meal taken at lunchtime only and does not indicate alternative options to the European diet. It was also noted that the menu was not followed on a number of occasions. The catering staff stated they were in the process of reviewing the menus and they have commenced using some fresh vegetables and fruit. It is recommended that the review of menus be done in consultation with residents so their preferences can be taken into consideration and menus reflect the meals provided. Also all residents must be given a choice at all meals. There are a number of residents who require a soft/liquidised diet and need assistance with feeding by staff. They were provided with assistance by staff appropriately. At lunchtime it was noted that meals were plated in the kitchen and were on a trolley in the dining room waiting to be served. Therefore meals were not maintained at an appropriate temperature. On discussion with some residents they stated meals were cold at times. This must be reviewed and a hot trolley provided for meals to maintain them at the appropriate temperature before serving. Residents stated the food was generally of a satisfactory standard, but the meat could be tough at times. It was noted that a number of residents were sitting in the dining room waiting for breakfast from 8am having received a hot drink. Although breakfast was served fairly promptly on the day of inspection a number of residents stated they had to wait until 9am of breakfast. These issues were raised at previous inspections and some changes had been made to address the issues, but it appears they are ongoing and this will need to be reviewed to ensure residents receive breakfast in a timely manner. Abbeydale Nursing Home DS0000024813.V328646.R01.S.doc Version 5.2 Page 17 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): 16,18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Complaint and concerns are not managed effectively and this does not give confidence the concerns will e listened to and addressed appropriately. EVIDENCE: The homes complaint procedure was on display in reception area. There were no formal complaints recorded in the homes record. The Commission received one complaint in December 2006 regarding medication, recruitment practices and manual handling. At inspection it was found that medication was not stored correctly, but regulations were met in other areas. During the inspection a complaint was received about residents not being fed, residents were loosing weight and food was being thrown away. This could not be evidenced on inspection and it regulations were being met. Whilst inspecting other record books it was noted that concerns/complaints had been raised and not addressed appropriately. Also issues were brought in the quality assurance questionnaires, but there was no evidence that they had been addressed. The records gave the impression of a defensive approach and less then open approach to complaints/concerns. Thus creating a culture where complainants cannot be confident that their concerns will be listened to in a positive and sensitive manner. This area will need to be reviewed and a more open approach adopted so that learning can take place and lead to improvements in systems. Also all concerns/complaints must be recorded Abbeydale Nursing Home DS0000024813.V328646.R01.S.doc Version 5.2 Page 18 appropriately with the nature of the complaint, the investigation, the findings, outcome, action taken and resolution. The home has adult protection procedures in place and some staff have been provided with training in this area. On discussion with them they were able to demonstrate an adequate knowledge. Prior to the inspection an incident of unexplained bruising was referred to Social Care and Health Department under the adult protection procedures and an investigation was undertaken. However, all procedures were not followed appropriately. This was discussed with the management of the home to enable learning to occur for the future. At the time of inspection a further referral was made to Social Care and Health in respect of another adult protection issue and the manager followed the correct procedures. The manager must ensue all staff are made aware of the correct procedures for the future. Abbeydale Nursing Home DS0000024813.V328646.R01.S.doc Version 5.2 Page 19 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 21,23,24,25,26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home is furnished to basic standards and a considerable amount of redecoration and maintenance is required. There are many requirements that need to be addressed in order to provide a more homely and safe environment for residents. EVIDENCE: Abbeydale Nursing Home DS0000024813.V328646.R01.S.doc Version 5.2 Page 20 On arrival it was noted that the exterior of the building requires decorating and a number of window frames need replacing, as they are damaged and the structural integrity is compromised. In order to gain access through the front door there are a number of steps. The home will need to provide suitable access e.g. ramped in order to meet resident’s needs who use wheelchairs and also the requirements of the Disability Discrimination Act that has come into effect. The garden to the rear of the property has had some work undertaken since the last inspection to clear it up, but further work is required to remove rubbish and make it fully accessible to residents and visitors when the weather permits. There is a large imposing reception area on entering the home. There is one large lounge that leads into the dining room on the ground floor and a further two small lounges to the rear of the building and they have been decorated recently. However, one of the lounges is poorly arranged as resident’s chairs are facing the wall. There is little stimulation, little room for movement and arrangements for staff observation are poor. The dining room and lounges were not measured, but do not appear to provide sufficient space for all residents. Previously it was stated that there were plans to increase the communal space and a conservatory was to be built, but the Commission have not received any plans to date. There are sixteen single rooms and eight double rooms of which seven have en-suite facilities, but some of the en-suite facilities are not suitable for use by residents with mobility problems. One of the double rooms is very small and is not suitable for two residents plus equipment etc. The home has been advised that this will need to become a single room and room 9 has a raised strip at the entrance of the door, which may be a trip hazard. Bedrooms do not have locks to doors and only some have lockable facilities provided. These areas will need to be addressed in order to uphold resident’s rights and privacy. All residents should be consulted about keys and where a key is not given a record retained in their file detailing why and be supported by a risk assessment. On inspection of a sample of rooms it was noted that some of the furniture was damaged or handles were missing. Screening was not sufficient in some bedrooms to promote privacy and dignity. All bedrooms did not have at least two double electrical sockets to allow for the use of electrical items and in one instance a double adaptor was in use, which is not acceptable under the regulations. A socket board should be used for safety purposes. Some bedside lights were not working and in other cases lights were not accessible from the bed; one bedroom had fluorescent lighting, which provide harsh lighting and is not homely; some commodes were damaged. Some bedrooms have been re-decorated, but there are still a number that require re-decoration to enhance the environment for residents. Abbeydale Nursing Home DS0000024813.V328646.R01.S.doc Version 5.2 Page 21 All areas are individually and naturally ventilated although some windows are difficult to access. Many of the radiators are covered with guards, but some of the radiator controls in resident’s rooms could not be adjusted to enable to temperature to be adjusted to suit individuals. It was noted that there were heaters in at least two rooms and it was stated that it did get cold at times. Also on discussion with residents some found the lighting was not adequate and it was stated that they had bought a light or a heater. The management of the home must ensure they provide suitable lighting and heating to all residents to meet their needs. There are a number of toilets and bathrooms in the home, but they are not easily recognisable as they have numbers on the doors, some did not have locks and the doors are not painted, which means that they cannot be cleaned easily. On discussion with one resident it was stated that the door blows open or people enter when using the toilet. This is an infringement of a resident’s privacy and an issue that remains outstanding for some time. It was noted the cistern in room 112 was still cracked and poses a risk to residents who use the toilet. Assisted bathing facilities are available on the ground and middle floor, however space is limited in the assisted bathing facilities and impacts on the privacy and dignity of residents, but also has implications for correct manual handling procedures. The proprietor will need to consider replacing these with more suitable facilities such as a flat floor shower. It was also noted that the bath seat in bathroom 113 was damaged; there was a window in the door with no screening and a boiler was housed there, but the door was not locked which poses a risk to residents. Some aspects in respect of infection control are poorly managed e.g. it was noted that some staff were walking around the home with latex gloves on. These gloves should be removed and hands washed after dealing with infected material or body fluids. There is only one sluicing disinfector on the ground floor, which was not working and this remains an outstanding requirement from the last inspection. The first and second floor does not have a sluicing disinfector. Each floor should have a sluicing disinfector and racking to store commode pots etc. Currently shelves are available and these are not considered good practice. The first floor sluice room has a toilet and the proprietor stated that it is not used. This should be removed so that temptation to use it is eliminated. Hand-washing facilities were variable in sluices and all these areas need to be addressed for adequate infection control procedures. The laundry walls have been painted and the floor covered, but the paint is peeling from one of the areas and this will need to be addressed. The laundry has a sluice sink. This should be removed and a hand-washing sink put in its place. This removes the temptation for staff to sluice items of laundry out, which is not necessary as both machines have a sluice cycle. Abbeydale Nursing Home DS0000024813.V328646.R01.S.doc Version 5.2 Page 22 On discussion with some residents they stated that clothing went missing and comments were also made about this are in the feedback from the quality assurance questionnaires that had been returned to the home. On discussion it was found that night staff are responsible for returning washing to residents rooms, which may be an explanation for the shortfalls in the system. This system should be reviewed. The home was in the main clean with the exception of areas such as the under side of commode chairs etc. The kitchen is situated on the ground floor and there is dedicated catering staff. At the time of inspection it was noted the fridge seals were damaged, tiles were missing, some of the cupboards were damaged some areas needed cleaning and spices were out of date. It was also noted that long life semi skimmed milk is in general use. However, there are some residents of low body weight who would benefit from the extra calories provided by full fat milk and some residents may prefer fresh milk. This area should be reviewed. Staff wash crockery etc and place it in a rinser. The proprietor was asked to forward the manufacturers details as to the temperatures attained by the rinser as it needs to be a minimum of 85 degrees for food hygiene control. If this temperature is not achieved an alternative must be obtained. The environmental health officer has recently undertaken an inspection of the kitchen and has made requirements of the home that need to be addressed in order to meet food hygiene standards. COSHH data sheets were available in the kitchen, but no risk assessments had been completed. Also kitchen staff need to carry out Hazeps analysis for food preparation. Abbeydale Nursing Home DS0000024813.V328646.R01.S.doc Version 5.2 Page 23 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 poor. This judgement has been made using available evidence including a visit to this service. Minimum staffing levels are maintained although some of the practices within the home potentially put residents at risk. There have been improvements in training so providing staff with the knowledge and recruitment procedures are fairly robust to protect residents. EVIDENCE: Since the last key inspection a new manager has come into post. The manager works five days per week of which three/four are supernumerary. At the time of inspection staffing levels were maintained at minimum levels. However, it was noted that staff were attending to residents on their own when it had been identified that there should be two members of staff. This was also an issue at a recent adult protection strategy meeting. The management team will need to review staffing levels and ensure there are adequate staff on duty at all times to meet residents needs. In addition to care staff there are domestic, catering, laundry activities and maintenance staff. A small sample of staff records were inspected in order to review recruitment procedures. It was found to be satisfactory with the exception of one new member of staff where a Criminal Record Bureau check had not been obtained prior to commencing employment. The Commission had been informed a disciplinary hearing with a member of staff had occurred recently, but there was no indication of this on the staff file. Information regarding staff Abbeydale Nursing Home DS0000024813.V328646.R01.S.doc Version 5.2 Page 24 disciplinary hearings and other relevant information should be retained on staff files for reference and to monitor progress. The home does have an induction programme for new staff and a copy was shown to the inspectors. It was noted the some induction training for new care staff had been undertaken over three days by senior carers. Although the programme covers a number of areas it does not meet the standards of the Skills Council standards, which now covers the first 12 weeks of employment and forms a foundation for NVQ training. It is recommended that the content and the process of induction training be reviewed and appropriate changes made to ensure it meets the standards and provides new staff with the appropriate knowledge to undertake their role initially. The information provided by the senior staff at the last inspection indicated that at least 50 of care staff had undertaken NVQ level 2 training, but there was no evidence to support this. At this inspection it was stated that two staff had completed the training recently, but evidence was not available. Other staff have started the training and the manager has supported staff with the training where required in order to provide them with the appropriate skills and knowledge to care for residents. Abbeydale Nursing Home DS0000024813.V328646.R01.S.doc Version 5.2 Page 25 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): 32,32,33,35,38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Team working and communication systems are poor as this could lead to poor outcomes for residents. Management systems are not sufficiently developed and the management of health and safety issues does not fully protect residents. EVIDENCE: A new manager took up post approximately five months ago. She is currently undertaking the Registered Managers Award and has been through the registration process with the Commission. She has been working hard and had a meeting with relatives, is having regular staff meetings and is introducing the Gold Standards Framework, which is a programme to enhance end of life care for residents. Abbeydale Nursing Home DS0000024813.V328646.R01.S.doc Version 5.2 Page 26 There is a quality assurance system and questionnaires had been sent out to relatives. Some had been returned with comments and suggestions. Also the manager had undertaken audits of the home and only two issues had been identified as requiring attention in order to meet the standards. There was no evidence of feedback from other stakeholders such as staff, visiting professionals, residents etc and there was no evidence to indicate that any action had been taken to address the issues raised by relatives or a development plan drawn up. It was positive that feedback had been obtained from relatives, but action needs to be taken to address the issues identified and also feedback needs to be obtained from other stakeholders in order to have a robust quality assurance system that will lead to improvements in the service. The proprietor had written some reports in respect of the conduct of the home as required under the regulations. However, these had not been completed every month and had not been forwarded to the Commission as required in order to inform the Commission of progress or events in the home. On discussion with some staff there appeared to be some problems in respect of changes that were occurring in the home and some staff stated they were not happy, but declined to give reasons. There appears to be a lack of team working as staff appear to have very rigid routines for each shift and staff from the next shift are unwilling to continue or finish jobs that they see as being the responsibility of the previous shift. The manager has identified some issues and areas of practice that need to be improved and made records which is positive as it will lead to improved outcomes for residents. However, the format of recording is not appropriate and this area needs to be reviewed and changed in line with data protection. There is a need for the management team to work together and demonstrate a team approach that is cascaded down to all staff and any issues or concerns discussed openly within the team in order to address the issues that are arising so that it does not affect outcomes for residents. The new manager has commenced formal staff supervision and records were available. Formal supervision should be undertaken at least six times a year by staff who have been trained in this area. It should cover all aspects of care, philosophy of care, career developments, welfare and any other issues raised. The accountant in the home holds money and records in respect of some resident’s personal monies. It was stated that they no longer receive the personal allowance for any residents and the Local Authority now manages these. On inspection it was noted the home still holds money for these residents in the homes bank account and is not acceptable as there should be a separate account for residents personal monies. All records are computerised and no signatures are available for transactions. The home buys toiletries in bulk and then they are charged to residents when they require them, but the cost does not reflect the actual cost of the items. (The Abbeydale Nursing Home DS0000024813.V328646.R01.S.doc Version 5.2 Page 27 Contract does state that where these services are provided by the home a supplementary charge may be made) On inspection of records it was found that records balanced with money held and receipts were available for purchases. The nurses also held money for two residents, receipts were not available for deposits and balances did not correspond with receipts for money spent on behalf of residents. This is not acceptable, as it does not demonstrate that resident’s money is being handled in a satisfactory manner. The system will need to be reviewed and it is recommended that one person take responsibility for resident’s personal monies. The home will need to ensure a separate account is opened in the name of residents and any interest is added on regularly. Also records must be kept of all money and valuables held on behalf of residents and receipts must be obtained for all deposits as well as withdrawals. Also there should be two signatures for each transaction, one preferably being the resident in order to demonstrate a robust system is in place. The records in respect of maintenance and servicing were inspected and some areas had been addressed. However, the following areas require attention in order to ensure all areas and equipment are safe so residents are not put at risk and health and safety standards are met. • There was no evidence for servicing of the passenger lift recently and some issues had been identified earlier, but there was no evidence to indicate that they had been addressed. • Evidence indicated that all portable hoists had not been serviced. • Bath seats had been serviced and issues had been identified in respect of hoist wheels on one and the base of the hoist on another that need to be addressed to ensure they are safe for use. • Testing of electrical appliances was overdue. • There was no evidence that the scales had been tested and calibrated. • The in house checks of hot water temperatures indicated that temperatures varied from 35 degrees to 44 degrees. Hot water at outlets accessible to residents should be maintained at 43 degrees centigrade. • There were some issues in respect of the emergency lighting and some electrical appliances that needed to be addressed and it was stated that they were waiting for an electrician to visit. However, it was noted that some of these issues had been present since December 2006. • Issues were raised at the last fire officer’s visit and there was no evidence to demonstrate that they had been addressed. • Risk assessments in respect of fire, chemicals, and environment need to be undertaken. Training records indicated that staff had undertaken training in respect of health and safety, tissue viability, promotion of continence, fire prevention and chemicals although certificates were not always available it was confirmed on Abbeydale Nursing Home DS0000024813.V328646.R01.S.doc Version 5.2 Page 28 discussion with staff. Training is required in infection control, moving and handling, first aid and basic food hygiene in order to ensure all staff have the skills and knowledge to meet residents needs. The manager stated she is hoping to undertake the manual handling trainers course in the near future, which would provide her with the knowledge to train staff and monitor practices in the home. Abbeydale Nursing Home DS0000024813.V328646.R01.S.doc Version 5.2 Page 29 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 1 2 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 2 1 1 1 X 2 1 1 1 STAFFING Standard No Score 27 1 28 1 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 1 2 X 1 2 X 2 Abbeydale Nursing Home DS0000024813.V328646.R01.S.doc Version 5.2 Page 30 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 5 Requirement The registered person must review the service user guide and ensure it provides accurate up to date information, include a copy of the contract and make them available to all residents. The registered person must ensure all residents have a contract or terms and conditions of residence and a copy must be kept on their file. The registered person must: • Ensure a comprehensive pre admission assessment is undertaken for all residents before entering the home that is signed and dated by the person undertaking the assessment. Timescale of 30/7/06 not met. The registered person must ensure that a comprehensive assessment is undertaken for all residents on admission to the home to include a mental health assessment, continence assessment, manual handling assessment, general risk DS0000024813.V328646.R01.S.doc Timescale for action 30/04/07 2 OP2 5 30/04/07 3. OP3 14 30/04/07 4. OP7 14 30/04/07 Abbeydale Nursing Home Version 5.2 Page 31 5. OP4 12(1) 18(1) 6. OP4 12(1) 13(4) 7. OP7 15 18(1) 8. OP8 13(1) assessment Timescale of 30/7/06 not met The registered person must ensure all staff undertake training in respect of caring for people with dementia commensurate with their position in the home. Timescale of 30/10/05 not met. The registered person must facilitate a suitable system for residents with dementia to be able to call for assistance or alert staff if they are getting out of bed when in their room. Timescale of 30/07/05 not met. The registered person must: • Ensure the care plan for each resident outlines in detail the action required by staff to meet all the residents needs. • The process must include consultation with the resident or their relatives. • Care plans must be reviewed monthly and updated where there are any changes. Timescale of 30/8/05 not met. • Training should be given in the care planning system where required. Timescale of 30/7/06 not met. The registered person must ensure all residents with chronic diseases such as diabetes, hypertension asthma, etc are reviewed on a regular basis by a health professional and records are retained in the home. Timescale of 30/12/05 not met. Systems must be in place for residents to see a dentist on a regular basis. 30/06/07 30/05/07 30/05/07 30/05/07 Abbeydale Nursing Home DS0000024813.V328646.R01.S.doc Version 5.2 Page 32 9. OP8 12(1) 10. OP8 12(1) 11 OP8 12(1) The registered person must 30/05/07 ensure all residents who require a wheelchair are referred for an appropriate assessment. The registered person must 30/03/07 ensure: • All staff use correct manual handling procedures and senior staff monitor this. Timescale of 15/5/06 not met. • All residents who requiring moving in bed have an individual slide sheet that is suitable for their needs. Timescale of 20/10/06 not met. • Suitable arrangements must be in place to ensure two staff are present for moving and handling residents where it is identified as necessary. 30/03/07 The registered person must ensure: • There is a proactive approach to care. • Follow up to areas of concern. • Suitable preventative strategies are put in place to reduce the risk of pressure sores and other complications. • Pressure relieving mattresses are connected properly to the mains electrical supply. • All alarms for pressure relieving mattresses are switched on to alert staff of any problems. • Dressings are changed on a regular basis and records reflect this. • The use of lemon and glycerine swabs is reviewed. • Where residents are of low weight suitable action is DS0000024813.V328646.R01.S.doc Version 5.2 Page 33 Abbeydale Nursing Home 12 OP8 13 OP8 OP10 14 OP8 15 OP15 taken to address the concern e.g. food charts, food boosters etc and referral to health professionals where necessary. • Ensure residents are supported properly when artificially feeding is in progress. 13(3) The registered person must: • Review infection control procedures in the home. • Review the use of latex disposable gloves. 12(1)(3) The registered person must review the arrangements for bathing and consult residents about their preferences. 13(4) The registered person must 12(1) ensure there is an adequate supply of suction catheters in the event of an emergency. 17(2) The registered person must 16(2)(i)12 ensure the record of food for all (4) residents is in sufficient detail for anyone inspecting to determine if they are receiving a nutritious diet. Timescale of 20/10/06 not met. The registered person must review the menus in consultation with residents and draw up one that offers choices; cultural options and their preferences are met. The registered person must provide a hot trolley for serving hot meals to ensure there are maintained at the correct temperature. 30/03/07 30/03/07 30/03/07 30/03/07 16 OP15 16(2)(j) 30/04/07 Abbeydale Nursing Home DS0000024813.V328646.R01.S.doc Version 5.2 Page 34 17 OP16 22 18. OP18 13(6) 19. OP19 23(2)(b) 20 21 OP19 OP19 13(3) 23(4) 22. OP19 23(2)(b) The registered person must ensure a robust procedure for dealing with all complaints to include: • All residents and relatives are made aware of the procedure. • Complaints are recorded appropriately and fully investigated. • The complaint record must indicate the nature of the complaint, the investigation, the findings, outcome and resolution. The registered person must ensure all staff are provided with training in respect of adult abuse, the procedures for responding to any allegations including the whistle blowing procedure. Timescale not met. The registered person must undertake an audit of the exterior of the home replace damaged windows and cladding and re-decorate. Timescale of 30/10/05 not met. The registered person must ensure clinical waste bins are locked when not in use. The registered person must ensure all fire doors are kept closed. If there is a need to keep them open they must be linked into the fire alarm system. The registered person must ensure the garden area is made suitable for residents to use when weather permits e.g. areas to walk and sit Timescale of 30/6/06 not met. • Remove rubbish and old bedsprings. 30/03/07 30/03/07 30/10/07 30/03/07 07/03/07 30/03/07 Abbeydale Nursing Home DS0000024813.V328646.R01.S.doc Version 5.2 Page 35 23 OP19 16(2)(j) 24 OP19 16(2)(j) 25. OP19 23(2)(n) DDA 26. OP20 23(2)(g) 27. OP21 12(4)(a) 28. OP21 23(2)(j) (n) The registered person must provide the Commission with information regarding the rinser in the kitchen to determine the temperatures achieved. Timescale of 15/6/06 not met. The registered person must: • Replace fridge door seals • Replace missing tiles • Replace damaged cupboards • Discard out of date items The registered person must provide suitable ramped access to the front of the building in order to meet residents needs and DDA Timescale of 30/8/06 not met. The registered person must provide plans with timescales for extension to the communal space. Timescale of May 2004 not met. The registered person must ensure appropriate safety locks are fitted to all toilet and bathroom doors to indicate when in use, but can be accessed in the event of an emergency. Timescale of 30/8/05 not met. The registered person must review the bathing facilities as outlined in the report and take appropriate action to provide facilities to meet residents needs and ensure health and safety guidelines are met Timescale of 30/7/06 not met. 30/03/07 30/03/07 30/06/07 30/06/07 30/03/07 30/06/07 Abbeydale Nursing Home DS0000024813.V328646.R01.S.doc Version 5.2 Page 36 29 OP21 13(3) 13(4) 30. OP23 23(2)(e) (f) 31. 32. OP23 OP24 23(2)(d) 16(2)(c) 33. OP24 12(4)(a) The registered person must; • Replace the cracked cistern in room 112. • Paint bathroom and toilet doors to enable easier recognition and cleaning. Timescale of 30/5/06 not met. • Provide a lock to the boiler room in the bathroom • Ensure hot water is available from all outlets. The registered person must provide information as to when the small double room will revert to a single room. Timescale of 30/7/05 not met. The registered person must continue with the redecoration of the home. The registered person must consult all residents as to the furnishings in their bedroom to determine their requirements. Where all the furnishings listed in the National Minimum Standards are not in bedrooms it must be recorded in residents files. If this is due to restrictions in space this must be made clear in the statement of purpose and service user guide. Timescale of October 2004 not met The registered person must provide: • Lockable facilities for all residents and locks to bedroom do. Residents must be consulted about holding their own keys and if they do not hold a key for any reason this must be recorded in their file. Timescale of 30/9/05 not met. 30/03/07 30/03/07 30/06/07 30/06/07 30/06/07 Abbeydale Nursing Home DS0000024813.V328646.R01.S.doc Version 5.2 Page 37 34 OP24 16(2) 35. OP25 12(4) 36. OP25 23(2)(p) The registered person must 30/04/07 • Provide a minimum of 2 double electrical sockets in each bedroom. Timescale of 30/7/05 not met. • Undertake an audit of all furnishings and replace damaged items. • Replace all double adaptors with a socket board. The registered person must 30/04/07 undertake an audit of all privacy curtains ensuring the rails are safe and the curtains extend around the circumference of the bed. Timescale of 19/1/06 not met. The registered person must; 30/04/07 • Audit all radiators and ensure residents can adjust them. • Ensure hot water from all outlets accessible to residents is maintained at 43 degrees or - 1 degree. • Replace fluorescent lighting in communal areas with something more domestic in character. • Ensure all lights have shades fitted, are accessible from resident’s beds and are in working order. Timescale of 30/7/05 not met. Replace fluorescent lighting in bedrooms with something that is more domestic in nature. • All areas of the home are kept warm at all times to meet resident’s needs. The registered person must ensure all areas of the home are kept clean at all times. • 37 OP26 23(2)(d) 30/03/07 Abbeydale Nursing Home DS0000024813.V328646.R01.S.doc Version 5.2 Page 38 38 OP26 13(4) 39 OP26 13(3) 40. OP26 13(3) 41 OP27 18(1) 42 OP28 18(1) 43 OP29 19(4) 44 OP30 18(1) The registered person must ensure all cleaning materials are kept in a locked cupboard when not in use. The registered person must ensure all staff remove gloves after dealing with infected materials and wash their hands in line with infection control procedures. The registered person must ensure there is a sluicing disinfector available on each floor that is in working order with appropriate racking and hand washing facilities in each sluice. Timescale of 30/5/06 not met. Ensure the laundry wall is treated and painted The registered person must ensure there are adequate staff on duty at all times to meet residents needs and where it is identified that two staff are needed to attend to a resident systems must be in place to ensure this happens. The registered person must ensure that at least 50 of care staff have completed NVQ level 2 and records are available in the home for inspection. Timescale of 30/10/06 not met. The registered person must ensure a CRB check is obtained for all staff before they commence employment in the home. The registered person must ensure all staff undertake induction training to Social Skills Council standards within 12 weeks of commencing employment. Timescale of 30/8/05 not met. 07/03/07 10/03/07 30/08/07 10/03/07 30/12/07 30/03/07 30/03/07 Abbeydale Nursing Home DS0000024813.V328646.R01.S.doc Version 5.2 Page 39 45 OP32 12(5) 12(1) 46. OP33 24(2)(3) 47. OP33 26 48 OP34 2017(2) The registered person must review and address current issues in the home and address shortfalls in team working and communication systems. The registered person must • Continue the process of obtaining feedback from residents, relatives and other stakeholders regarding the home and draw up an action plan indicating developments and outcomes for residents. Timescale of not met. • Follow up the issues and take action in respect of the issues identified in the feedback from relatives. The registered provider must undertake a visit to the home each month, write a report, which is signed, leave a copy with the home and forward a copy to the Commission. Timescale of February 2003 not met. The registered person must ensure: • All resident’s money is deposited in an account, which bears the names of residents. • There must be two signatures for all transactions made on behalf of residents ideally one being the residents. Timescale 15/12/05 not met. • Records must be maintained for all money held in the home on behalf of residents. • Receipts must be available for all deposits and withdrawals. 30/04/07 30/06/07 30/03/07 15/04/07 Abbeydale Nursing Home DS0000024813.V328646.R01.S.doc Version 5.2 Page 40 49 OP36 18(2) 50. OP38 18(1) 51. OP38 13(4) The registered person must ensure systems are in place where staff receive formal supervision at least six times a year by a person who has undertaken training in this area. The process must cover all areas outlined in the standards and records must be retained in a confidential manner in the home to demonstrate this. Timescale of 30/12/05 not met. The registered person must ensure all staff undertake basic training in respect of basic food hygiene, infection control, first aid and records must be retained home. Timescale of 30/12/05 not met. The registered person must undertake risk assessments in respect of chemicals, fire and environment with appropriate action plans to reduce risk. 30/06/07 30/06/07 30/06/07 Abbeydale Nursing Home DS0000024813.V328646.R01.S.doc Version 5.2 Page 41 52 OP38 13(4) 17(2) The registered person must 15/04/07 ensure • The passenger lift is serviced and records retained in the home. • Testing of electrical appliances is undertaken. • All hoists are serviced/inspected on a regular basis and records are retained in the home. • The issues in respect of the bath seats are addressed. • The issues in respect of the electrical appliances and emergency lighting are addressed. • Action is taken to maintain all water from hot water outlets at 43 degrees or – one degree. • The scales are serviced/calibrated and evidence is retained in the home. Abbeydale Nursing Home DS0000024813.V328646.R01.S.doc Version 5.2 Page 42 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 OP3 OP3 Good Practice Recommendations It is recommended that the assessment tool for manual handling and continence is reviewed and training provided where appropriate. (Carried forward) It is recommended that the manger liaise with social workers to obtain a copy of the assessments they have undertaken for all residents admitted to the home. (Carried forward) It is recommended that the home provide suitable equipment for orientation of residents and take advice about colours etc when decorating the home. (Carried forward) Ensure all creams are dated when opened and discarded within specified timescales. It is recommended that activities co-ordinator undertakes some formal training and records of activities undertaken by residents are maintained. 3. OP4 4 5 OP9 OP12 Abbeydale Nursing Home DS0000024813.V328646.R01.S.doc Version 5.2 Page 43 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Home DS0000024813.V328646.R01.S.doc Version 5.2 Page 44 - 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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