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Inspection on 21/10/05 for Abbeydale Nursing Home

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

This inspection was carried out on 21st October 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

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 also reflected in the staff group. They provide a choice of meals including cultural options, which residents enjoyed and stated they received good portions. A dedicated activities co-ordinator is employed and has undertaken training in this area.

What has improved since the last inspection?

The manager stated that there has been some staff training since the time of the last inspection.

What the care home could do better:

There has been little development since the last inspection and many of the requirements still need to be addressed and the managements will need to take more positive action to address these issues in a timely manner and demonstrate the home is being well managed. There needs to be a more proactive approach to care especially in relation to tissue viability and further improvements in the medication system are required to ensure residents receive the correct medication at all times.The home has also been asked to undertake a review of equipment e.g. beds, chairs and pressure relieving equipment to ensure that it meets the needs of residents. Further improvement in infection control procedures are also required. The management must ensure robust recruitment procedures are implemented with all checks completed before staff commence employment to ensure residents are adequately protected. Further decoration and re-furbishment is required to enhance the surroundings and provide a homely environment. Further training is required to ensure staff have the appropriate skills and knowledge to care for residents and fully meet their needs. Records of the training completed by staff must be available to demonstrate the training has been completed. The assessment and care planning process needs to be enhanced to ensure resident`s needs are identified and appropriate plans of action put into place. In addition, staff numbers need to be increased in the afternoon to ensure all resident`s needs are fully met. 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. The arrangements for resident`s finances need to be reviewed and separate bank account arrangements put in place. A number of areas in respect of the maintenance and servicing of equipment need to be addressed with some urgency. The home is failing to provide good outcomes for residents.

CARE HOMES FOR OLDER PEOPLE Abbeydale Nursing Home 88 Handsworth Wood Road Handsworth Wood Birmingham West Midlands B20 2PL Lead Inspector Ann Farrell Unannounced Inspection 21st October 2005 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Abbeydale Nursing Home DS0000024813.V260605.R01.S.doc Version 5.0 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.V260605.R01.S.doc Version 5.0 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 Pearl Zukiswa Kutase 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.V260605.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The home may provide care, by reason of physical disability, for one named person, (KJ), who is below the age of 65 years That Mrs Kutase successfully completes the Registered Care Managers Award or equivalent by April 2005. 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 one named service user can be accommodated in the home who is under 65 years of age. 2/6/05 4. 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 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 facilities are not suitable for residents with mobility problems. A passenger lift gives access to all floors. There is a separate laundry facility where laundering of all linen and clothing is undertaken and the kitchen is situated on the ground floor. 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. The home accepts residents 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 DS0000024813.V260605.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection was conducted over one and a half days commencing at 7.30am on 21st October 2005. The registered manager was present for the first day of the inspection and the proprietor was present during the remaining part. During the inspection process the inspector toured the home, sampled residents files and other documentation in respect of the management of the home. The manager, three members of staff and four residents were spoken to. A number of residents were unable to communicate verbally and case tracking was undertaken. What the service does well: What has improved since the last inspection? What they could do better: There has been little development since the last inspection and many of the requirements still need to be addressed and the managements will need to take more positive action to address these issues in a timely manner and demonstrate the home is being well managed. There needs to be a more proactive approach to care especially in relation to tissue viability and further improvements in the medication system are required to ensure residents receive the correct medication at all times. Abbeydale Nursing Home DS0000024813.V260605.R01.S.doc Version 5.0 Page 6 The home has also been asked to undertake a review of equipment e.g. beds, chairs and pressure relieving equipment to ensure that it meets the needs of residents. Further improvement in infection control procedures are also required. The management must ensure robust recruitment procedures are implemented with all checks completed before staff commence employment to ensure residents are adequately protected. Further decoration and re-furbishment is required to enhance the surroundings and provide a homely environment. Further training is required to ensure staff have the appropriate skills and knowledge to care for residents and fully meet their needs. Records of the training completed by staff must be available to demonstrate the training has been completed. The assessment and care planning process needs to be enhanced to ensure resident’s needs are identified and appropriate plans of action put into place. In addition, staff numbers need to be increased in the afternoon to ensure all resident’s needs are fully met. 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. The arrangements for resident’s finances need to be reviewed and separate bank account arrangements put in place. A number of areas in respect of the maintenance and servicing of equipment need to be addressed with some urgency. The home is failing to provide good outcomes for residents. 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 DS0000024813.V260605.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Abbeydale Nursing Home DS0000024813.V260605.R01.S.doc Version 5.0 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 the following standard(s): 1,2,3,4,6 The home has available for prospective residents and their relatives information about the services and facilities. The admission documents had not all been completed appropriately and without these it cannot be guaranteed that residents needs will be identified and met. EVIDENCE: The home generally admits residents for long-term care, but on occasions they have admitted residents for respite care. There is a service user guide available for prospective residents providing them with information about the facilities and services. It states that a large print document is available on request, which is to be commended. However, the home has residents from various ethnic groups and they will need to provide the document in relevant languages or other forms so that it is accessible to all prospective residents and their families. A copy of the statement of purpose held by the Commission is out of date and it was noted that it refers to a number of procedures. This needs to be updated and where procedures are referred to a copy of the procedures must Abbeydale Nursing Home DS0000024813.V260605.R01.S.doc Version 5.0 Page 9 be included. When this has been completed a copy should be forwarded to the Commission. A copy of the terms and conditions of residence was provided for inspection and it was noted that it includes details of how to make complaints. It refers to the National Care Standards Commission, which no longer exists and states that if the complainant is not happy with the investigation undertaken by the home they can refer it to the Commission. Residents and their representatives have the right to contact the Commission at any stage of a complaint and this needs to be reflected in the document. A small selection of residents files were inspected and there was evidence of a pre-admission assessment, but there was no evidence to indicate staff had written to prospective residents to confirm if they could meet their needs following assessment. On admission there was evidence of further details taken and past history, which was good. The record of assessments following admission to the home included risk assessments in respect of tissue viability, nutrition, manual handling, the use of bedrails etc. It was noted that some of these did not have the name of the resident, had not been fully completed, were not accurate or had not been completed in some cases. In some cases the assessment was not comprehensive e.g. the manual handling assessment did not cover all areas where manual handling may be required. Also some were vague and 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 mental health where resident suffered with dementia. The staff weigh residents on admission to the home, but there was no evidence of any tool to determine if the body weight is satisfactory such as body mass index. Some staff have undertaken some training in respect of caring for people with dementia, but this needs to be put in place for all staff to ensure they have the appropriate skills and knowledge. The manager stated that since the last inspection she has been reviewing methods for residents to alert staff that they are in need of assistance when in their bedrooms, but has not found anything suitable to date. Some of the rooms are small and it would be difficult to manoeuvre equipment such as hoists for manual handling. Residents with mobility problems cannot access some of the en-suite facilities, as they are not large enough. The home has three passive hoists, a slide sheet and handling belts to assist with manual handling. Abbeydale Nursing Home DS0000024813.V260605.R01.S.doc Version 5.0 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 the following standard(s): 7,8,9,10 The systems in place do not meet the health care needs of residents. Improvement of the medication system is required to ensure residents receive the medication prescribed. EVIDENCE: 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. On inspection of a sample of records it was noted that they gave vague instructions and were not comprehensive. There was no indication of involvement of the resident or their representative and they had not been reviewed monthly by staff to determine if the plan of care was still appropriate. There was evidence of an annual review in one file, which was very brief and gave very little information about any progress or changes. The records include separate sheets to indicate visits by the G.P. and other health professionals. There was evidence of visits by the G.P and a dietician and the record of the chiropodists visits was recorded in a diary, but there was no indication of which resident was seen. The home will need to ensure records of health professional visits indicate the name of the resident and the outcome of the visit. During the inspection a part set of dentures were found in a drawer in the clinical room. Apparently they were given to a member of staff by a Abbeydale Nursing Home DS0000024813.V260605.R01.S.doc Version 5.0 Page 11 relative who stated they were poorly fitting, but this issue had not been followed up. It was also noted that the bed safety rails were not of sufficient height on beds where some pressure relieving equipment was in use and the blood glucose of one diabetic resident had not been recorded since March. At the time of inspection the manager stated the tissue viability nurse was visiting a resident with pressure sores and was arranging for a profiling bed. It appears that the resident had no pressure sores on admission to the home and over the period of a month there was a general deterioration and the development of pressure sores. However, the home did not contact the tissue viability nurse until the sore had developed and it suggests that the programme of pressure relief was not appropriate for this resident as prevention of pressure sores should be the goal. In addition, issues were raised at the last inspection about the equipment such as beds and chairs for residents and no action has been taken about this to date. The manager and staff need to develop a more proactive approach to care and a review of equipment such as beds, chairs, pressure relieving equipment and manual handling equipment must be undertaken. During the inspection it was noted that a catheter night bag had been removed, emptied and left on a stand apparently for use again. However, there was no cap on the end of the tube and this could lead to urinary infections. The care plans do not give specific instructions about the use of catheters and catheter care for residents. It was suggested that the manager should contact the infection control nurse and work with her in respect of an audit and training in infection control. A number of residents have wheelchairs and it was stated that the home had purchased some new wheelchairs since the time of the last inspection. It was not clear that residents had been assessed for wheelchairs and on one occasion it was noted that the residents feet had fallen behind the footplates and would puts resident’s at risk. The home uses a monitored dosage system of medication, which is stored appropriately. On inspection of the medication charts it was noted that the current prescriptions were not available to check against MAR charts. The manager stated that they were routinely photocopied and were available else where, but they were not seen by the inspector. It is recommended that copies of prescriptions are kept with the relevant MAR chart to enable easier auditing. It was noted that the home did not have copies of current prescriptions to check medication on admission to the home. A number of audits were undertaken and some were found to be inaccurate in the boxed medication, eye drops had not been dated with the date of opening, the home had run out of medication for one resident for a number of days, there was no indication in records when there had been a change in the dose of medication and staff were administering medication to residents from other residents supplies of medication. Staff must ensure that they only administer Abbeydale Nursing Home DS0000024813.V260605.R01.S.doc Version 5.0 Page 12 medication to residents from their own supply to enable auditing to be undertaken. There was no suction equipment available and the machine for monitoring blood glucose had dried blood on it creating a risk of cross infection. During inspection it was also noted that staff were mixing medication for one resident in food. This is classed, as covert administration of medication is not acceptable practice unless it has been agreed at a multidisciplinary meeting and the pharmacist. The manager was advised of the need to arrange such a meeting and records of the meeting are to be kept in the home. On discussion with resident’s they stated they were well looked after and staff were good. Staff treated residents with respect. There is a telephone in the reception area and a hand held set when privacy is required. Abbeydale Nursing Home DS0000024813.V260605.R01.S.doc Version 5.0 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13,14,15 The meals offered a choice and enjoyed by residents. The arrangements for breakfast need reviewing as residents who are up early had to wait for a considerable period. There is a range of recreational activities, but it cannot be guaranteed that they meet resident’s preferences as no assessments had been completed in respect of this aspect. EVIDENCE: Residents are free to come and go as they wish and there are no rigid rules. Visiting is flexible and feedback indicated that relatives can visit then they wish. Residents are able to bring personal items of furnishings etc into the home and it was stated they may get up, go to bed and spend time as they wish An activities co-ordinator is employed in the home and the manager stated she had recently undertaken some training in this area. At the time of inspection the children from a local school visited celebrating Harvest Festival and exercises to music in the afternoon. On discussion with one resident she stated that they play dominoes and cards and sit out in the garden when the weather permits. The hairdresser visits when required. Abbeydale Nursing Home DS0000024813.V260605.R01.S.doc Version 5.0 Page 14 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 and four times per week there is an Afro Caribbean option. The inspector observed part of the lunch. On arrival at 7.30am there were eight residents sitting in the dining room. There was no evidence that they had received a drink and on discussion with one resident’s he stated he had not had a drink that morning. Breakfast was not served until approximately 9.15am. when staff arrive on duty they are busy with getting the remaining residents washed/dressed and up. The inspector was concerned that residents had to wait for such a long period before having any breakfast and it is recommended that practices be reviewed. The home has many residents with high dependency needs and a number require assistance with feeding therefore lunch is divided into two sittings. 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. The home retains a comprehensive record of food taken by residents who experience some problems. However, other records in the kitchen were not comprehensive and had not been completed every day to determine that all residents were receiving a nutritious and balanced diet. Records of food taken by residents must be retained for three years. Abbeydale Nursing Home DS0000024813.V260605.R01.S.doc Version 5.0 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 The procedures in place for complaints failed to demonstrate that concerns had been addressed fully; therefore, residents may not be fully protected. EVIDENCE: The home has a complaints procedure displayed on the notice board in the reception, however it does not indicate clearly the complaints may approach the Commission. Since the inspection the home has updated the procedure and provided a copy to the Commission. On inspection of the homes record of complaints it was found that it did not give details of investigation, outcome and resolution consistently, which is required in order to demonstrate the complaints have been dealt with appropriately. Since the inspection the home has advised the Commission in Writing that all staff have undertaken training in respect of vulnerable adult procedures. Records were not inspected at this time and it will be followed up at the next inspection. Abbeydale Nursing Home DS0000024813.V260605.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The home is furnished to basic standards and a considerable amount of redecoration is required. The environment does not always provide a homely and comfortable environment for residents in all areas. EVIDENCE: Abbeydale Nursing Home DS0000024813.V260605.R01.S.doc Version 5.0 Page 17 On arrival it was noted that the exterior of the building requires decorating and some of the window frames need replacing or repair. There is one large lounge that leads into the dining room on the ground floor. The carpet in the lounge required cleaning, it was starting to fray at the entrance to the dining room and it was not securely fitted to the step in the corner of the room. Also the lighting was inadequate in this area. There are another two small lounge areas. However, one of these is poorly arranged as resident’s chairs are facing the wall and there is little room for movement. Also there is no call bell in the room and it was found to be noticeably cooler than the remaining of the building. 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 the plans have not been submitted to the Commission and no timescales have been given as to when the work will be carried out. 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 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 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, 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 and 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 some of the radiator controls in resident’s rooms could not be adjusted. At the time of the last inspection it was noted that the temperature of the water from one shower was 58 degrees, which presents a significant risk for residents. The manager stated that they have been unable to do anything about this and the shower will have to be removed. Abbeydale Nursing Home DS0000024813.V260605.R01.S.doc Version 5.0 Page 18 On discussion with the manager she stated that the requirements identified at the time of the last inspection in respect of the building had not been addressed. Therefore they have all been carried forward. 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. On discussion with some residents they stated that clothing went missing from the laundry on occasions. The laundry system will need to be reviewed and any action taken to ensure residents receive they’re clothing back. The kitchen is situated on the ground floor and there is dedicated catering staff. At the time of inspection it was noted the mesh to the window was not adequate; the door to the kitchen was left open and there was no mesh in place; spices had been decanted into jars and there was no use by date; the freezer compartment of the fridge had no door; the hand basin was cracked and needs replacement. Also the fryer was not working, the floor covering was damaged and the use and storage of mops within the kitchen area needs to be managed more hygienically. Abbeydale Nursing Home DS0000024813.V260605.R01.S.doc Version 5.0 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,30 The procedures for the recruitment of staff are not robust and do not provide the safeguards to offer protection to residents 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 are 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 resident’s needs. On discussion with residents they stated the home was good and staff were always busy. Feedback from the quality questionnaires also indicated that staff are stretched at times. A small sample of staff records were inspected in order to review recruitment procedures. It was noted that a member of staff had recently been employed without a POVA check. Homes should not employ any member of staff unless they have undertaken relevant checks e.g. two written references, POVA and CRB check. In some cases there was only one reference, nurses PIN numbers Abbeydale Nursing Home DS0000024813.V260605.R01.S.doc Version 5.0 Page 20 had expired, there was no evidence of eligibility to work in the country, there was no evidence that a CRB check had been completed for some staff and a risk assessment had not been completed following a positive CRB. The proprietor has received a letter of serious concern and immediate action must be taken to address these issues. Records of induction training on one file had not been completed and there was no evidence of induction on other files. Abbeydale Nursing Home DS0000024813.V260605.R01.S.doc Version 5.0 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,38 The quality assurance system needs to be developed further and systems put in place to address issues raised with an approach of continuous improvement. Action needs to be taken to manage resident’s monies in a more open and accessible manner. Resident’s health safety and well-being could be enhanced by the prompt servicing of equipment. EVIDENCE: The manager has been in post approximately two years and is undertaking the Registered Managers Award, which is a condition of her registration. The home has a quality assurance system in place and there was evidence of some feedback forms from relatives and staff plus audits that had been undertaken by the manager. It was noted that issues had been raised on the feedback forms, but there was no evidence that any action had been taken to address them and there was no development plan based on outcomes for Abbeydale Nursing Home DS0000024813.V260605.R01.S.doc Version 5.0 Page 22 residents. Also it was apparent from some of the comments that relatives were no aware of meetings that occur in the home. There was evidence that there had been three staff meetings and two residents meeting this year. Yet again there was no evidence of follow up in respect of issues raised by the manager. Formal staff supervision has not been undertaken regularly. Supervision must be undertaken at least six times a year and include all aspects of practice, philosophy of care and career development. On discussion with staff they stated they enjoyed working in the home, they felt they worked as a team and found the manager very good. They confirmed that there was a verbal handover at the change of shift. Records available at the time if inspection indicated that there had been three visits (April, July, October) on behalf of the responsible individual. However, these must be undertaken once a month and records retained in the home for inspection. The home holds money and valuables on behalf of residents an on inspection it was found that all records are computerised as the accountant deals with it. There was no record of the valuables held, no signatures for transactions and no receipts from people such as hairdresser and chiropodist. 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 Contract does state that where these services are provided by the home a supplementary charge may be made) The money is paid into the homes account and remains there until it is used, therefore residents do not receive any interest payments. Also the accountant has estimated the cost of items for some residents for the period from admission to the time he took over the management of finances and deducted a set amount without any evidence of receipts or expenditure e.g. £407-75 for one resident. In some cases it was noted that residents were buying their own armchairs, which are in the lounge and were paying for a taxi and escort to the hospital or health centre. The accountant also asked about charging residents an administration fee for handling the records etc. None of these expenditures are acceptable and will be discussed with the owners in further detail to secure a satisfactory outcome for residents. The home will need to ensure a separate account is opened in the name of residents and any interest is added on regularly. Records must be kept of all money and valuables held on behalf of residents and receipts must be obtained from anyone providing a service such as hairdressing, chiropody etc. Also there should be two signatures for each transaction, one preferably being the resident. Abbeydale Nursing Home DS0000024813.V260605.R01.S.doc Version 5.0 Page 23 A sample of maintenance and servicing records were inspected. Records for servicing of some items were available, but the following areas needed addressing: • Portable electrical appliances. • The fire alarm and emergency lighting system. • The fire extinguishers. • An inspection of the gas equipment. • Servicing of the passenger lift and inspection by the insurers. • The call bell system. • Portable hoists and bath seats. Also some fire doors were propped open and some doors were not closing properly into the rebate. On discussion with staff there was a lack of clarity about the fire procedure. The manager stated that there had been some training since the last inspection including basic food hygiene, communication, manual handling, health and safety and staff were currently undertaken infection control training. Inspection of records did not confirm that this training had been completed and some of the records indicated that the last training was some two to three years ago. The manager will need to ensure all training records are up to date with evidence that training has been completed. Abbeydale Nursing Home DS0000024813.V260605.R01.S.doc Version 5.0 Page 24 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 2 2 2 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 X 2 2 2 2 2 2 2 2 STAFFING Standard No Score 27 2 28 X 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 2 2 X 1 X 2 Abbeydale Nursing Home DS0000024813.V260605.R01.S.doc Version 5.0 Page 25 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 4 Requirement The registered person must ensure the service users guide is available in other languages or formats suitable for the client group admitted to Abbeydale Nursing Home. The registered person must update the statement of purpose and include any procedures referred to. When this has been completed a copy must be forwarded to the Commission. The registered person must: • Must write to all residents or their representatives 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 must be undertaken where residents suffer with dementia. Version 5.0 Page 26 Timescale for action 30/01/06 2 OP2 5 30/01/06 3. OP3 14 30/12/05 • • Abbeydale Nursing Home DS0000024813.V260605.R01.S.doc 4 OP4 12(1) 18(1) 5. OP4 12(1) 13(4) 6. OP7 15 7. OP8 13(1) The nutritional assessment must include an objective tool such as BMI or similar tool. • All risk assessments must be comprehensive, accurate, signed, dated and include the resident’s name. Timescale of 30/8/05 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 to meet the residents needs, they must be specific to the needs and must include consultation with the resident or their relatives. Care plan must be updated following monthly evaluation where there are any changes and the record of reviews must be more comprehensive. Timescale of 30/8/05 not met The registered person must ensure: • All residents have opportunity 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, DS0000024813.V260605.R01.S.doc • 30/03/06 30/12/05 30/12/05 30/12/05 Abbeydale Nursing Home Version 5.0 Page 27 8. OP8 12(1) hypertension asthma, etc are reviewed on a regular basis by a health professional. Timescale of 30/07/05 not met. The registered person must: Ensure that all residents who require a wheelchair are referred for an appropriate assessment and follow up the area identified in respect of the wheelchair at the time of inspection. • Undertake an audit of all seating and referrals made to an occupational therapist for suitable seating where appropriate. Timescale of 30/8/05 not met. • Undertake an audit of all bed safety rails and replace any that are not of sufficient height to safeguard residents. • Follow up the issue in respect of resident’s illfitting dentures. • Ensure resident’s diabetes is monitored on a regular basis. The registered person must undertake an audit of all beds, pressure relieving equipment and manual handling equipment ensuring it is appropriate to meet the needs of residents. The registered person must review the practices in respect of catheter care and the use of catheter bags. It is suggested that the infection control nurse is contacted for advise and training in respect of infection control. The registered person must ensure all nurses undertake training in respect of tissue DS0000024813.V260605.R01.S.doc 30/11/05 • 9 OP8 12(1) 15/12/05 10 OP8 12(1) 15/12/05 11 OP8 18(1) 30/12/05 Abbeydale Nursing Home Version 5.0 Page 28 12 OP9 13(2) viability and ensure systems are in place to address any concerns regarding tissue viability promptly. The registered person must 05/11/05 ensure a robust system for medication to include: • Photocopies of all prescriptions 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. • Ensure systems are in place so that the home does not run out of medication. • The date eye drops are opened must be recorded on the container. Timescale of 30/6/05 not met. • Ensure there are clear records to indicate when the dose of medication is changed. • Ensure a record is made of the amount of medication administered when variable doses are prescribed. • Staff must only administer medication to residents from their own supply of prescribed medication. • Ensure the blood glucose monitoring machine is kept clean. • Provide suction equipment and ensure senior staff are aware of its whereabouts. • Convene a multidisciplinary meeting regarding the resident where medication DS0000024813.V260605.R01.S.doc Version 5.0 Page 29 Abbeydale Nursing Home is being given covertly and obtain advise from the pharmacist. 13. OP12 16(2)mn1 2(2)14 The registered person must ensure an assessment of residents past interests and hobbies is undertaken and they are consulted about any activities. Following this a plan may be drawn up for group and individual activities 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. Timescale of 30/6/05 not met The registered person must review the current arrangements for breakfast consulting all residents who are up early in the morning. The registered person must ensure a record of all complaints are held in the home indicating the nature of the complaint, investigation, outcome and resolution. 30/12/05 14. OP15 17(2) 15/11/05 15 OP15 16(2)(i) 12(4) 15/11/05 16 OP16 22 30/11/05 17. OP18 13(6) The registered person must 30/12/05 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. This are was not inspected and has been carried forward. Since the inspection the manager has informed the Commission that all staff have undertaken this training DS0000024813.V260605.R01.S.doc Version 5.0 Page 30 Abbeydale Nursing Home 18. OP19 23(2)b) 19 OP19 16(2)(j) 13(3) and it will be followed up at the next inspection. The registered person must 30/06/06 undertake and audit of all windows and replace where necessary and re-decorate the exterior of the building. Timescale of 30/10/05 not met. The registered person must 15/12/05 address the outstanding issues from the environmental health officers report and include; replacement of wash hand basin, mesh to windows and door, provide freezer door to fridge, all decanted food items must have a use by date and a hygienic system for mops, replace the flooring in the kitchen and the fryer that is not working. The registered person must incorporate some fresh vegetables in the main meals. Timescale of 30/6/05 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 if it is in use, but can be accessed in the event of an emergency. Timescale of 30/8/05 not met. The registered person must replace damaged flooring in the bathroom on the ground floor. Timescale of 30/8/05 not met. The registered person must ensure a call bell is available in the small lounge used by residents. The registered person must provide information as to when the small double room will revert DS0000024813.V260605.R01.S.doc 20 OP19 16(2)(i) 15/11/05 21. OP20 23(2)(g) 30/11/05 22. OP21 12(4)(a) 30/11/05 23. OP21 13(3)(4) 30/11/05 24 OP22 23(2)(n) 30/11/05 25. OP23 23(2)(e) (f) 30/11/05 Abbeydale Nursing Home Version 5.0 Page 31 26. OP23 23(2)(d) 27. OP24 16(2)(c) 28. OP24 12(4)(a) 29. OP24 16(2) 30. OP25 23(2)(p) to a single room. Timescale of 30/7/05 not met. The registered person must ensure all areas in the home are decorated to a suitable standard. Provide an action plan indicating dates for re-decoration. Timescale of 30/7/05 not met. The registered person must consult all residents as to the furnishing 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 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 their file. Timescale of 30/9/05 not met. The registered person must; Undertake an audit of all furnishings and replace any damaged items. Replace hospital beds as identified at previous inspection Timescale of October 2004 not met. Provide a minimum of 2 double electrical sockets in each bedroom. Timescale of 30/7/05 not met. The registered person must; Audit all radiators and ensure they can be adjusted by residents and re covered. 30/11/05 30/11/05 30/12/05 30/12/05 30/11/05 Abbeydale Nursing Home DS0000024813.V260605.R01.S.doc Version 5.0 Page 32 Ensure hot water from all outlets accessible to residents must be 43 degrees or - 1 degree. Fluorescent lighting in communal areas must be replaced with lighting, which is more domestic in character. Ensure all lights have shades fitted and are accessible from resident’s beds. Timescale of 30/7/05 not met. Ensure there is adequate lighting in the large lounge. The registered person must ensure all areas of the home are heated adequately for residents at all times. The registered person must: Ensure the laundry is redecorated so that walls are readily cleanable. The flooring is replaced with a suitable alternative that is impermeable. Dedicated hand washing facilities must be available in all areas where clinical waste or infected materials are handled. Ensure the sluicing disinfector is fully operational at all times. Timescale of 30/8/05 not met. The registered person must 05/11/05 ensure all staff must remove gloves and wash hands after dealing with body fluids or clinical waste. The registered person must 15/11/05 ensure that the carpet in the lounge is cleaned and made safe. The registered person must 30/11/05 review the laundry system and address any issues to ensure all DS0000024813.V260605.R01.S.doc Version 5.0 Page 33 31 OP25 23(2)(p) 10/11/05 32. OP26 13(3) 30/12/05 33 OP26 13(3) 34 35. OP26 OP26 23(2)(d) 13(4) 12(1) Abbeydale Nursing Home 36. OP26 13(4) 37. OP27 18(1) 38. OP29 19 residents clothing is returned to them in a timely manner. The registered person must ensure a risk assessment is undertaken in respect of sluice areas and any action taken as identified to ensure the safety of residents. Timescale of 30/6/05 not met. 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 two written 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 September 2003 not met. The registered person must ensure all staff must undertake induction training Social Skills Council standards within 12 weeks of commencing employment. Timescale of 30/8/05 not met. The registered manager must successfully complete the Registered Managers Award. Timescale of 30/9/05 not met. The registered person must obtain feedback from residents, relatives and other stakeholders regarding the home and draw up an action plan indicating DS0000024813.V260605.R01.S.doc 30/11/05 15/11/05 15/11/05 39. OP30 18(1) 30/11/05 40. OP31 9(2) 30/03/06 41. OP33 24(3) 30/01/06 Abbeydale Nursing Home Version 5.0 Page 34 outcomes for residents. Timescale of 30/9/05 not met. Where any issues are identified from feedback there must be appropriate mechanisms to address the issues and provide evidence of the action taken. 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 their names and interest must be added regularly to individual accounts. Records of all transactions must be maintained with receipts from the services provided or any items purchased on residents behalf. There must be two signatures for all transactions ideally one being the residents. The registered person must ensure that systems are in place where staff receive formal supervision at least six times a year and records are retained in the home. 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. Timescale of 30/7/05 not met. The registered person must ensure all staff undertake training in respect of basic food hygiene and records must be retained home. DS0000024813.V260605.R01.S.doc 42. OP33 26 30/11/05 43 OP34 20 17(2) 15/12/05 44 OP36 18(2) 30/12/05 45. OP38 23(4)(d) (e) 30/11/05 46. OP38 16(2)(j) 30/12/05 Abbeydale Nursing Home Version 5.0 Page 35 47. OP38 13(3) 48. OP38 13(4) 49. OP38 13(4) The registered person must 30/01/06 ensure all staff undertake training in respect of infection control and records must be retained home. The registered person must 30/03/06 ensure all staff undertake training in respect of first aid and records must be retained in the home. Timescale of October 2004 not met. The registered person must 30/11/05 ensure the following servicing is undertaken and records are retained in the home: Fire alarm system Call bell system Emergency lighting All gas appliances are checked and a gas safety certificate is available. All portable electrical appliances are checked. All hoists and bath seats are serviced. Address issues in respect of the passenger lift and obtain a report from the insurers. 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 OP9 Good Practice Recommendations It is recommended that the assessment tool for manual handling and continence is reviewed and training provided where appropriate. It is recommended that the photocopies of prescriptions are retained with the relevant MAR chart. Abbeydale Nursing Home DS0000024813.V260605.R01.S.doc Version 5.0 Page 36 Commission for Social Care Inspection Birmingham Office 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. 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