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Inspection on 02/06/05 for Abbeydale Nursing Home

Also see our care home review for Abbeydale Nursing Home for more information

This inspection was carried out on 2nd June 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

On discussion with residents they stated they were happy in the home and staff looked after them well. The home admits residents from a range of cultural backgrounds and the cultural mix of staff 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.

What has improved since the last inspection?

The home has provided a second assisted bathing facility and has met some of the requirements of the last report. Since the last inspection the home has started a staff training programme and it was felt that morale had improved as a result of this.

What the care home could do better:

Further decoration and re-furbishment is required to enhance the surroundings and provide a homely environment. There needs to be a more robust recruitment procedure in place and staff training needs to be extended to all staff in the home from induction and basic mandatory training up to specialist training in areas such as dementia. The assessment and care planning process needs to be enhanced to ensure residents needs are identified and appropriate plans of action put in to place.In addition, staff numbers need to be increased in the afternoon to ensure all residents needs are fully met.

CARE HOMES FOR OLDER PEOPLE Abbeydale Nursing Home 88 Handsworth Wood Road Handsworth Wood Birmingham B20 2PL Lead Inspector Ann Farrell Unannounced 2 June 2005 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 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 E54 S24813 Abbeydale NH V230100 020605 Stage 2.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Abbeydale Nursing Home Address 88 Handsworth Wood Road Handsworth Wood Birmingham B20 2PL 0121 554 5024 0121 523 6001 Telephone number Fax number Email 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 Pearl Zukiswa Kutase Care Home 35 Category(ies) of Older People, Dementia registration, with number of places Abbeydale Nursing Home E54 S24813 Abbeydale NH V230100 020605 Stage 2.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may provide care, by reason of physical disability, for one named person, (KJ), who is below the age of 65 years. 2. That Mrs Kutase successfully completes the Registered Care Managers Award or equivalent by April 2005. 3. 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. 4. That one named service user can be accommodated in the home who is under 65 years of age. Date of last inspection 13 October 2004 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. There is a large garden to the rear of the home, with a barbeque area. 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. Abbeydale Nursing Home is situated in a residential area of Birmingham. The railway station is nearby and the home is on a bus route. There are two main communal sitting rooms on the ground floor, a small quiet room and a dining room. There are sixteen single bedrooms plus eight double bedrooms and seven have en-suite facilities. However all en-suite facilites are not suitable for residents with mobility problems. A passenger lift gives access to all floors. There is a separate laudnry facility where laundering of all linen and clothing is undertaken. The kitcehn is situated on the ground floor. The home accepts service users from a wide variety of cultural and ethnic backgrounds. This cultural mix is reflected in the staff seen working in the home. Abbeydale Nursing Home E54 S24813 Abbeydale NH V230100 020605 Stage 2.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was conducted on an unannounced basis over a full day commencing at 8.15 am on 2nd June 2005. The registered manager and deputy were present for some of the inspection and feedback was given at a later date. During the inspection process the inspector toured the home, sampled residents files and other documentation. The manager, one member of staff and approximately six residents were spoken to. A number of residents were unable to communicate verbally. What the service does well: What has improved since the last inspection? What they could do better: Further decoration and re-furbishment is required to enhance the surroundings and provide a homely environment. There needs to be a more robust recruitment procedure in place and staff training needs to be extended to all staff in the home from induction and basic mandatory training up to specialist training in areas such as dementia. The assessment and care planning process needs to be enhanced to ensure residents needs are identified and appropriate plans of action put in to place. Abbeydale Nursing Home E54 S24813 Abbeydale NH V230100 020605 Stage 2.doc Version 1.30 Page 6 In addition, staff numbers need to be increased in the afternoon to ensure all residents needs are fully met. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Abbeydale Nursing Home E54 S24813 Abbeydale NH V230100 020605 Stage 2.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Abbeydale Nursing Home E54 S24813 Abbeydale NH V230100 020605 Stage 2.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3,6 The pre admission assessments were not available for all residents without which there is no assurance that the care needs of residents will be identified and met. EVIDENCE: The home admits residents in need of long term care. At the time of the last inspection it was stated that a statement of purpose and service users guide was available and it was suggested that it should be available in different languages, as the home has a number of residents from various cultural backgrounds. A small selection of residents files were inspected and on some there was no evidence of a pre admission assessment or a written letter indicating that the home could meet the prospective residents needs. The manager informed the inspector at the time of feedback that pre-admission assessments are retained in a separate area. Abbeydale Nursing Home E54 S24813 Abbeydale NH V230100 020605 Stage 2.doc Version 1.30 Page 9 The record of assessments following admission to the home included risk assessments in respect of tissue viability, nutrition, manual handling, use of bedrails, wheelchair and hoist on occasions. It was noted that on one file there was information about past history and lifestyle, but this was not available on all files. Information was vague, lacked detail and some areas in standard 3 of the National Minimum Standards were not covered. There was no evidence of any input form any other significant people such as relatives, G.P. hospital etc. There was no assessment in respect of continence problems or mental health where a resident’s suffered with dementia. It was noted that one nutritional assessment indicted that a male resident weighed 49.5 kg on admission and it was considered an average weight. However, the inspector would consider this to be rather low. The home should have a more objective method of assessing residents weight such as a record of body mass index. If anyone is below a BMI score of 20 they are considered to be at risk and a referral should be made to appropriate health professionals On inspection of a small number of staff training files it was noted that some staff had undertaken training in respect of an introduction to dementia. As the home is registered for dementia it is necessary for all staff to undertake training in respect of dementia commensurate with their position in the home. At previous inspections it was noted that the home needed to make improvements in the facilities and equipment for meeting residents needs and this remains unchanged. During a tour of the home the manager informed the inspector that residents with dementia were not provided with call bell extension leads due to the risk. The manager will need to arrange a suitable alternative method for these residents to either call for assistance or alert staff that they are out of bed when in their bedrooms. Some of the rooms are small and it would be difficult to manoeuvre equipment such as hoists and some of the en-suite facilities could not be accessed by residents with mobility problems. The home has three passive hoists, a slide sheet and handling belts. During the inspection it was noted that one member of staff was using a handling belt on her own to stand a resident. Care must be taken with using handling belts as they are only designed to guide and support where residents are able to able to rise from a sitting position. This practice was indicative of the need for all staff to have current training in respect of moving and handling. Abbeydale Nursing Home E54 S24813 Abbeydale NH V230100 020605 Stage 2.doc Version 1.30 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8.9 Staff do not have adequate information to enable them to enable them to meet the personal and health needs of residents. Medication systems in the home do not adequately protect residents and ensure that they receive prescribed medication as required. EVIDENCE: On inspection the home had drawn up care plans for all residents. On inspection of a small sample it was noted that some areas lacked detail as to how needs were to be met e.g. care of catheter, type of hoist and size of sling to be used care of the PEG feeding site etc. There was no indication of involvement of the resident or their representative. One care plan stated that incontinent pads and sheets should be used for the management of continence when a resident was on bed. On another file it was noted that a resident had developed a pressure sore approximately six months after admission to the home. The water flow risk assessment identified that there was a risk on admission, but there was no indication of any pressure relieving equipment in use until treatment of the sore commenced. Abbeydale Nursing Home E54 S24813 Abbeydale NH V230100 020605 Stage 2.doc Version 1.30 Page 11 It was noted that two care plans had been drawn up by the home three days apart and they gave different directions as to how often the dressing should be renewed and the type of dressing. The resident was seen by the tissue viability nurse some six weeks later who identified problems with the seating and repositioning of the resident. She also made a recommendation that the G.P. should be contacted in respect of nutritional supplements. There was no evidence in the care plan that the resident was receiving nutritional supplements. Some residents were to have a thickener in drinks and there was no evidence of this on care plans. Care plans had been reviewed monthly by staff and there was no evidence of updating. An annual review of one of the care plans had been undertaken in one case and there was only one sentence recorded. The records include separate sheets to indicate visits by the G.P. and other health professionals. Although there was evidence of visits by the G.P and a dietician there was no evidence of visits by the chiropodist, optician or dentist. A number of residents have wheelchairs, but some have not been assessed by an appropriate individual to ensure they are suitable for the resident. The home uses a monitored dosage system of medication, which is stored appropriately. On inspection of the medication it was noted that the home did not have copies of prescriptions to check medication on admission to the home. A number of audits were undertaken and were found to be inaccurate both in the monitored dosage system and the boxed medication, handwritten prescription details had not been countersigned by two staff, codes had been used and not explained and at one time it was noted that the home had run out of medication. On examination of one MAR chart it was noted that diabetic medication had been omitted at least twice a week and staff were giving sugar drinks, as it was felt that the blood sugar was too low. This was discussed and it is recommended that the G.P. or the diabetic nurse specialist be contacted for advice and that protocols be drawn up for staff to use. Abbeydale Nursing Home E54 S24813 Abbeydale NH V230100 020605 Stage 2.doc Version 1.30 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,15 The meals offered a choice, were of a good standard and enjoyed by residents, but did not include fresh vegetables. The recreational activities provided do not satisfy residents own hobbies or previous interests. EVIDENCE: The home has an activities co-ordinator who is employed on a full time basis. The manager stated that the activities co-ordinator will be attending some training in the near future. Records of activities undertaken in the home included such aspects as singing, story reading, manicures, reminiscence. On inspection of resident’s records there was no evidence of assessment of residents previous interests/hobbies and one care plan had very vague generalised comments. The home will need to undertake assessments of residents previous interests and hobbies and draw up a plan of activities either group or individual in order to meet their needs. At the time of inspection it was noted that the television and radio were on simultaneously in the lounge. Staff should consult residents as to which they would prefer. Abbeydale Nursing Home E54 S24813 Abbeydale NH V230100 020605 Stage 2.doc Version 1.30 Page 13 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 lunch time and four times per week there is an Afro Caribbean option. The inspector observed part of the lunch. There are approximately ten residents who require a soft/liquidised diet and need assistance with feeding by staff and they are usually attended to at the first sitting. This is followed by a second sitting for the remaining residents. On discussion with residents they stated they enjoyed the meals. At present the home uses only frozen vegetables, consideration must be given to using fresh ingredients to ensure that the food served is wholesome, balanced and nutritious. Staff were noted to provide assistance to residents where required and the meals were unhurried. However, some staff stood up when providing the assistance. This is not good practice and needs to be reviewed. The home retains a comprehensive record of food taken by residents who experience some problems. However, other records in the kitchen lacked detail and some were not dated. On discussion with the cook she was unable to state the period of time records were maintained. Records of food taken by residents must be retained for three years. Abbeydale Nursing Home E54 S24813 Abbeydale NH V230100 020605 Stage 2.doc Version 1.30 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 Staff require training in the adult abuse procedures to ensure robust procedures are in place and all residents are adequately protected. EVIDENCE: The inspector did not see the homes procedures in respect of complaints or protection from abuse. On discussion with one of the senior members of staff she was not aware of the local guidance in respect of the procedures for dealing with any allegations of abuse. All staff will require training in this area. Abbeydale Nursing Home E54 S24813 Abbeydale NH V230100 020605 Stage 2.doc Version 1.30 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19.20.21.23.24.25,26 The home is furnished to basic standards and does not always provide a homely and comfortable environment for residents in all areas. EVIDENCE: Abbeydale Nursing Home E54 S24813 Abbeydale NH V230100 020605 Stage 2.doc Version 1.30 Page 16 On arrival it was noted that the exterior needs decorating and some of the window frames look as if they need replacing or repair. There is one large lounge that leads into the dining room on the first floor. In addition there are another two small lounge areas. However, one of these is poorly arranged as resident’s chairs are facing the wall. The dining room and lounges were not measured, but do not appear to provide sufficient space for all residents. Apparently there are plans to extend the home, which will increase the communal space, but no timescales for the work to be done have been notified. 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 the home has been advised that this will need to become a single room. 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 residents 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 an inspection of a sample of rooms it was noted that the hinged door to some of the top compartments of wardrobes had no mechanism for remaining open; all rooms did not have at least two double electrical sockets and double adaptors were in use; some lights did not have shades; some commodes were rusting; a number of rooms require re-decoration; rooms did not have the furniture listed in the standards and some of the furniture was damaged. Some bedrooms did not have lights that could be accessed from beds and there were fluorescent lights in some of the communal areas used by residents, which provide harsh lighting are is not homely. At the time of the last inspection it was noted that the hospital type beds were of a poor standard and the home was required to replace them. Only one has been replaced and this issue remains outstanding. All areas are individually and naturally ventilated although some windows are difficult to access. Many of the radiators are covered with guards, but it was noted that one had not been covered and some of the radiator controls in resident’s rooms could not be adjusted. On testing the temperature of water it was found to be cool to touch in a number of areas, but the temperature of the water from one shower was 58 degrees, which presents a significant risk for residents. The hot water from all outlets accessible to residents should be 43 degrees or – 1 degree. Abbeydale Nursing Home E54 S24813 Abbeydale NH V230100 020605 Stage 2.doc Version 1.30 Page 17 Since the time of the last inspection the home has fitted an extra assisted bathing facility. It was noted that some of the toilet/bathing facilities did not have a suitable lock on the door and the flooring in one bathroom was damaged under the toilet and will need replacement to enable thorough cleaning to take place. The home has a separate laundry area with dedicated staff. On inspection it was noted that the area requires decorating and new flooring. There are dedicated sluice areas and one has a sluicing disinfector. However, these areas do not have dedicated hand washing facilities and at the time of inspection the sluicing disinfector could not be accessed. It was also noted that there is no lock on the sluice doors and residents may wander in to them. A risk assessment must be undertaken and locks fitted where appropriate. All areas where infected material or clinical waste is handled must have dedicated hand washing facilities and the sluicing disinfector must be fully operational at all times. During the inspection it was noted that some staff were walking around the home with vinyl gloves on. These gloves are for use when dealing with infected material or body fluids and should be removed afterwards in keeping with good infection control procedures. The kitchen is situated on the ground floor and there is dedicated catering staff. At the time of inspection it was noted that that some decanted foods were in containers with poorly fitting lids and there was no use by date; some of the crockery was chipped and will need replacing; food temperatures are not recorded and the cleaning schedule was not completed appropriately. Also the fryer was not working and the floor covering was damaged and will need replacing. The standard of cleaning in the home needs further attention as it was noted that beds and pieces of equipment such as hoists and bath seats required cleaning. Whilst touring resident’s rooms it was noted in one double room that there were three wash bowls and they were not labelled to indicate which residents they were for. Abbeydale Nursing Home E54 S24813 Abbeydale NH V230100 020605 Stage 2.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29,30 The procedures for the recruitment of staff are not robust and do not provide the safeguards to offer protection to people living in the home. The number of staff available in the afternoon/evening is not sufficient to meet the needs of residents. EVIDENCE: The manager works five days per week of which three are supernumerary. At the time of inspection there were two nurses and five care staff on duty during the morning and two nurses and three care staff on duty during the evening. On inspection of duty rotas and discussion with staff it was found that these levels are usually maintained. In addition, there is domestic, catering, laundry activities and maintenance staff. Although the staffing levels appeared satisfactory for the morning shift it was not adequate after 2pm when the morning shift go off duty. The home has a number of highly dependent residents and there are at least ten who require some assistance with feeding. These staffing levels for the evenings will need to be increased in order to meet residents needs. On discussion with residents they stated the home was good and staff were always busy. A small sample of staff records were inspected to review recruitment procedures. It was not always clear who references came from and in one instance it was noted that references had been obtained from two friends. Some of the application forms had gaps in the employment history, some had no copy of CRB or POVA check, or they were from previous employers. One overseas member of staff work permit was valid for a previous home. Abbeydale Nursing Home E54 S24813 Abbeydale NH V230100 020605 Stage 2.doc Version 1.30 Page 19 The manager had checked the Nurse PIN numbers, but there was no date of checking and these should be checked on a regular basis. Records of induction indicated that care staff had undertaken the homes induction over two days. However, the training provided does not meet the TOPPS requirements. Abbeydale Nursing Home E54 S24813 Abbeydale NH V230100 020605 Stage 2.doc Version 1.30 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,33,38 Training needs to be made available to all staff to ensure they have the appropriate knowledge to meet resident’s needs. EVIDENCE: The manager has been in post approximately two years and is undertaking the Registered Managers Award, which is a condition of her registration. She stated that she hopes to complete it in the next two months. The manager stated that the home has achieved a quality assurance award. In order to meet the standards the home will also need to obtain feedback from residents and other stakeholders and draw up an action plan for development based on outcomes for residents. The manager stated that residents meetings and relatives meetings are held quarterly Abbeydale Nursing Home E54 S24813 Abbeydale NH V230100 020605 Stage 2.doc Version 1.30 Page 21 The home had one report that had been completed in April 2005 following a visit by the proprietor or his representative, but it had not been signed. Visits must be undertaken each month and a report completed, signed and made available in the home and sent to the Commission. It was noted that comments from residents indicated that staff were always busy. Maintenance records of requirements from the last inspection were only checked at this inspection and the home had addressed them. Training records indicated that some staff had not undertaken the basic mandatory training e.g. fire prevention and drills, moving and handling, infection control, basic food hygiene and first aid. During the inspection it was noted that staff were wearing inappropriate footwear and may be a risk under health and safety. Abbeydale Nursing Home E54 S24813 Abbeydale NH V230100 020605 Stage 2.doc Version 1.30 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 2 2 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 2 COMPLAINTS AND PROTECTION 2 2 2 x 2 1 2 1 STAFFING Standard No Score 27 2 28 x 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 2 2 x 2 x x x x 2 Abbeydale Nursing Home E54 S24813 Abbeydale NH V230100 020605 Stage 2.doc Version 1.30 Page 23 no Are there any outstanding requirements from the last inspection? 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 3 Regulation 14 Requirement The registered person must; Must write to all residents or their represntatives to confirm if the home is able to meet their needs at the time of the assessment. Assessments must cover all areas included in standard 3 of the National Minimum Standards and include consultation with other relevant people where required. Assessments of mental health and continece must be underaken where residents suffer with dementia or incontinence. The nutritional assessment must include an objective tool such as BMI or similar tool. Risk assessments must indicate details of the risks. The registered person must ensure all staff undertake training in respect of caring for people with dementia commensurate with their position in the home. The registered person must facilitate a suitable system for residents with dementia to be Timescale for action 30/8/05 2. 4 12(1) 18(1) 30/10/05 3. 4 12(1) 13(4) 30/7/05 Abbeydale Nursing Home E54 S24813 Abbeydale NH V230100 020605 Stage 2.doc Version 1.30 Page 24 4. 7 15 5. 8 13(1) 6. 8 12(1) 7. 8 12(1) 18(1) 13(2) 8. 9 able to call for assisstance or alert staff if they are getting out of bed when in their room. The registered person must ensure the care plan for each resident outlines in detail the action required to meet the residents needs, they must be specific to the needs and must include consultation with the resident or their relative. Care plan must be updated following monthly evaluation where there is any changes and the record of reviews must be more comprehensive. The registered person must ensure: All residents have oppportunity to see the chiropodist, optician and dentist on a regular basis and records are retained in the home. All residents with chronic diseases such as diabetes, hypertension asthma, etc are reviewed on a regular basis by a health professional. The registerd person must: Ensure that all residents who require a wheelchair are referred for an appropraite assessment. Undertake an audit of all seating and referrals made to a occupational therapist for suitable seating where appropraite. Ensure there are systems in place to provide residents with regular pressure relief where appropriate. The registered person must ensure staff receive training in respect of management of continence. The registerd person must ensure a robust system for medication to include: 30/8/05 30/7/05 30/8/05 30/8/05 30/6/05 Abbeydale Nursing Home E54 S24813 Abbeydale NH V230100 020605 Stage 2.doc Version 1.30 Page 25 9. 12 16(2)(m) (n) 12(2) 14 10. 15 17(2) 11. 18 13(6) 12. 19 23(2)b) Photocopies of all prescritpions must be obtained and all medication entering the home checked against it. Timescale of October 2004 not met. The accurate administration and recording of medication. All medication awaiting return to the chemist must be kept in a locked cupboard. All codes must be clearly explained. Two members of staff must countersign any handwritten medication details. Ensure systems are in place so that the home does not run out of medication. The current temperature of the drug fridge should be recorded daily. The date eye drops are opened must be recorded on the conatiner. The registerd person must ensure an assessment of residents past interests and hobbies is undertaken and they are consulted about any activies. Following this a plan may be drawn up for group and individual acitivites to meet their needs. Timescale of February 2003 not met. The registered person must ensure the record of food for all residents is in sufficient detail for anyone inspecting to determine if they are receiving a nutritious diet. The registerd person must ensure all staff undertake training in respect of the action to take in the event of any allegation of abuse. Records of training to be retained in the home. The registered person must 30/8/05 30/6/05 30/7/05 30/10/05 Page 26 Abbeydale Nursing Home E54 S24813 Abbeydale NH V230100 020605 Stage 2.doc Version 1.30 13. 20 23(2)(g) 14. 21 12(4)(a) 15. 16. 21 23 13(3)(4) 23(2)(e) (f) 23(2)(d) 17. 23 18. 24 16(2)(c) 19. 24 12(4)(a) undertake and audit of all windows and repalce where necessary and re-decorate the exterior of the building. The registered person must provide plans with timesclaes for extension to the communal space Timescale of May 2004 not met. The registered person must ensure appropraite safety locks are fitted to all toilet and bathroom doors to indicate if it is in use, but can be accessed in the event of an emergency. The registered person must replace damaged flooring in the bathroom on the ground floor. The registerd person must provide information as to when the small double room will revert to a single room. The registerd person must ensure all areas in the home are decorated to a suitable standard. Provide an action plan indicating dates for re-decoration. The registered person must consult all residents as to the furnishing in their bedroom to determine their requirments. 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 restricitons in space this must be made clear in the statement of purpose and service user guide. Timescale of October 2004 not met. The registerd person must provide lockable facilities for all residents and locks to bedroom doors. 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 30/7/05 30/8/05 30/8/05 30/7/05 30/7/05 30/7/05 30/9/05 Abbeydale Nursing Home E54 S24813 Abbeydale NH V230100 020605 Stage 2.doc Version 1.30 Page 27 their file. 20. 24 16(2) The registrered person must; Undertake an audit of all funishings and replace any damaged items. Replace hosptial beds as identified at previous inspeciton. Timescale of October 2004 not met. Provide a minimum of 2 double electrical sockets in each bedroom. The registered person must; Audit all radiators and pipework and provide covers where they are not in place. Ensure hot water from all outlets accessible to residents must be 43 degrees or - 1 degree. Flourescent lighting in communal area must be replaced with lighting which is more domestic in charater. Ensure all lights have shades fitted and be accessible from residents beds. The registered person must: Replace chipped crockery Ensure all decanted foods are in containers with close fitting lids and are dated. Record the temperature of hot foods. Ensure the cleaning schedule is completed regularly. Replace the flooring in the kitchen. Replace the fryer that is not working. The registered person must incorporate some fresh vegetables in the main meals. The registered person must: Ensure the laundry is redecorated so that walls are readily cleanable. The flooring is replaced with a 30/7/05 21. 25 23(2)(p) 30/7/05 22. 19 16(2)(j) 30/6/05 23. 24. 19 26 16(2)(i) 13(3) 30/6/05 30/8/05 Abbeydale Nursing Home E54 S24813 Abbeydale NH V230100 020605 Stage 2.doc Version 1.30 Page 28 25. 26 23(2)(d) 26. 26 13(4) 27. 27 18(1) 28. 29 19 29. 30 18(1) suitable alternative that is impermeable. Dedicated handwashing facilites must be available in all areas where clinical waste or infected materials are handled. Ensure the sluicing disinfector is fully operational at all times. Staff must remove gloves and wash hands after dealing with body fluids or clinical waste. The registered person must ensure all areas and equipment in the home is kept clean at all times. The registered person must ensure a risk assessment is undertaken in respect of sluice areas and any action taken as identified. The registered person must ensure the staffing levels are increased to provide at least a ratio of 1 member of staff to five residents. If the home wishes to vary their staffing levels a formal written proposal must be made to the Commission. The registered person must ensure a robust recruitment procedure is in place to include references from previous employers, a valid work permit, and a POVA check must be available before commencing employment. Also a full CRB must be obtained. The date nurses PIN numbers are checked must be recorded and they must be checked on a regular basis. Timescale of Septemebr 2003 not met. The registered person must ensure all staff must undertke induction training to TOPPS standards within 6 weeks of commencing employment. 30/7/05 30/6/05 30/6/05 30/6/05 30/8/05 Abbeydale Nursing Home E54 S24813 Abbeydale NH V230100 020605 Stage 2.doc Version 1.30 Page 29 30. 31. 31 33 9(2) 24(3) 32. 33 26 33. 38 23(4)(d) (e) 34. 38 16(2)(j) 35. 38 13(3) 36. 38 13(4) 37. 38 13(5) The registered manager must successfully complete the Registered Managers Award. The registered person must obtain feedback from residents, relatives and other stakeholders regarding the home and draw up an action plan indicating outcomes for residents. The registerd 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. Timsclae of Februarly 2003 not met. The registered person must ensure all staff undertake training in respect of fire prevention and at least 2 fire drills per year and records must be retained in the home. The registered person must ensure all staff undertake training in respect of basic food hygiene and records must be retained home. Timescale of October 2004 not met. The registered person must ensure all staff undertake training in respect of infection control and records are retained home. Timesclae of October 2004 not met. The registered person must ensure all staff undertake training in respect of first aid and records are retained in the home. Timescale of October 2004 not met. The registered person must ensure all staff undertake training in respect of moving and handling and reocrds must be retained in the home. Timscale of October 2004 not met. 30/9/05 30/9/05 30/6/05 30/7/05 30/9/05 30/10/05 30/11/05 30/7/05 Abbeydale Nursing Home E54 S24813 Abbeydale NH V230100 020605 Stage 2.doc Version 1.30 Page 30 38. 39. 38 15 13(4) 12(1) 40. 8 12(1) The registered person must ensure all staff wear appropriate footwear when on duty. The registered person must ensure all staff sit with residents when providing assisstance with feeding them. The registered person must ensure nursing staff undertake training in respect of tissue viability and blood glucose monitoring. 30/6/05 30/6/05 30/7/05 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. 3. Refer to Standard Good Practice Recommendations Abbeydale Nursing Home E54 S24813 Abbeydale NH V230100 020605 Stage 2.doc Version 1.30 Page 31 Commission for Social Care Inspection 1st Floor Ladywood House 45-46 Stephenson Street Birmingham, B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Abbeydale Nursing Home E54 S24813 Abbeydale NH V230100 020605 Stage 2.doc Version 1.30 Page 32 - 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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