Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 26/04/06 for Abbeydale Nursing Home

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

This inspection was carried out on 26th April 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 living in the home. The home admits residents from a range of cultural backgrounds and the cultural mix of residents is also reflected in the staff group. They provide a choice of meals including cultural options, which residents enjoyed and stated they received good portions. A dedicated activities co-ordinator is employed and an organisation who visits regularly for movements to music. There is a stable staff group who are pleasant and have potential to develop to enable them to further meet the needs of residents.

What has improved since the last inspection?

The home has employed a new manager with considerable experience in the nursing field. He has good clinical knowledge and enthusiastic about improving standards, but had only recently been in post and had a strategy in place to implement improvements in areas such as care planning etc. The new manager is introducing a key worker and named nurse system in order to improve the delivery of care to residents. He has made some changes in respect of catheter management to reduce the risk of infection and has undertaken an audit of medication and has an action plan to improve this area. The tissue viability nurse has undertaken an audit and is working closely with the home. As a result of the audit the home are purchasing a range of new equipment. The tissue viability nurse was very pleased with the developments in the home and stated that staff were welcoming, always provided an escort, followed instructions and discussed any problems with her. There have been some improvements in the recruitment process and the home is now undertaking POVA checks before staff commence employment in the home. The fencing in the garden has been renewed, so improving security. Training needs have been identified and arrangements made for staff training.

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. The proprietors will need to take more positive action to address these issues in a timely manner and demonstrate the home is being well managed. Re-decoration and re-furbishment with replacement of windows and attention to the garden area is required to enhance the surroundings and provide a homely environment for residents. Further improvements in infection control procedures are required with staff training, practices and equipment. The management need to further develop the recruitment procedures before staff commence employment to ensure residents are adequately protected. 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 systems for dealing with concerns and complaints needs to be reviewed and a more pro-active approach taken to ensure residents are adequately protected. The arrangements for resident`s finances 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 to ensure a safe environment for residents. The arrangements for activities and stimulation of residents needs to be reviewed and enhanced to ensure residents needs re being met.

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 26th April 2006 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Abbeydale Nursing Home DS0000024813.V289678.R01.S.doc Version 5.1 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.V289678.R01.S.doc Version 5.1 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 Vacant 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.V289678.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 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 two-named service users can be accommodated in the home who are under 65 years of age. 21st October 2005 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. A large garden is situated to the rear of the home. The area at the front of the home is made over largely for car parking, which is limited and contains well established herbaceous and shrub borders. The home accepts residents from a wide variety of cultural and ethnic backgrounds. This cultural mix is reflected in the staff seen working in the home. Abbeydale Nursing Home DS0000024813.V289678.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first key inspection and was undertaken on an unannounced basis over two full days on 26th April 2006 commencing at 7.30am 27th April. The new manager and proprietor were present for the duration of the inspection. Two inspectors undertook the inspection and the process included a tour of the home, inspection of records and documents relating the management of the home and staff. Case tracking of resident’s records was undertaken to determine care from the time of admission. The manager, six members of staff and seven residents were spoken to. number of residents were unable to communicate verbally. A The inspection identified many areas that need to be addressed in order to meet the regulations and residents needs effectively. As a result of the inspections a significant number of requirements have been made, a number of which remain outstanding from previous inspections. The home will need to make significant improvements in order to address the areas identified or the Commission may need to take action. Since the inspection a meeting has been held with the providers and they have assured the Commission that a number of areas have been addressed. What the service does well: What has improved since the last inspection? The home has employed a new manager with considerable experience in the nursing field. He has good clinical knowledge and enthusiastic about improving standards, but had only recently been in post and had a strategy in place to implement improvements in areas such as care planning etc. Abbeydale Nursing Home DS0000024813.V289678.R01.S.doc Version 5.1 Page 6 The new manager is introducing a key worker and named nurse system in order to improve the delivery of care to residents. He has made some changes in respect of catheter management to reduce the risk of infection and has undertaken an audit of medication and has an action plan to improve this area. The tissue viability nurse has undertaken an audit and is working closely with the home. As a result of the audit the home are purchasing a range of new equipment. The tissue viability nurse was very pleased with the developments in the home and stated that staff were welcoming, always provided an escort, followed instructions and discussed any problems with her. There have been some improvements in the recruitment process and the home is now undertaking POVA checks before staff commence employment in the home. The fencing in the garden has been renewed, so improving security. Training needs have been identified and arrangements made for staff training. What they could do better: There has been little development since the last inspection and many of the requirements still need to be addressed. The proprietors will need to take more positive action to address these issues in a timely manner and demonstrate the home is being well managed. Re-decoration and re-furbishment with replacement of windows and attention to the garden area is required to enhance the surroundings and provide a homely environment for residents. Further improvements in infection control procedures are required with staff training, practices and equipment. The management need to further develop the recruitment procedures before staff commence employment to ensure residents are adequately protected. 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. Abbeydale Nursing Home DS0000024813.V289678.R01.S.doc Version 5.1 Page 7 The systems for dealing with concerns and complaints needs to be reviewed and a more pro-active approach taken to ensure residents are adequately protected. The arrangements for resident’s finances 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 to ensure a safe environment for residents. The arrangements for activities and stimulation of residents needs to be reviewed and enhanced to ensure residents needs re being 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 DS0000024813.V289678.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Abbeydale Nursing Home DS0000024813.V289678.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 4, 6 Quality in this outcome area is poor. The judgement has been made using available evidence including a visit to this service. The home has available for prospective residents and their relative’s information about the services and facilities, but they required amending to ensure accurate information is provided. 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, but some of the information is not accurate and this document will need to be reviewed and amended. A small selection of resident’s files were inspected and there was a lack of information in respect of residents needs. Also there was no evidence Abbeydale Nursing Home DS0000024813.V289678.R01.S.doc Version 5.1 Page 10 available to indicate that staff had written to prospective residents to confirm if they could meet their needs on admission to the home. Following admission to the home there was evidence that details and past history were taken plus risk assessments in respect of tissue viability, nutrition, manual handling, the use of bedrails etc. It was noted that some of these risk assessments had not been completed and there was some conflicting information in some of them. In some cases the assessment was not comprehensive and the information was vague. There was no assessment in respect of mental health or continence, where residents had needs in these areas and there was no evidence that the resident or any other significant person such as relatives, G.P. hospital etc. had been involved in the process. A nutritional assessment is undertaken, but there is no objective tool to determine if the body weight is satisfactory such as body mass index and all residents are not weighed on admission to the home. One resident smoked and there was no risk assessment in place plus there were no risk assessments in respect of any other areas of risk that may occur e.g. going out, using the passenger lift on their own, using the stairs etc. The home has employed a new manager since the last inspection. He is aware of the shortfalls in the recording system and is hoping to introduce new documentation in order to address it. The home has a number of residents who suffer with confusion or dementia and at previous inspections it was identified that training was required in this area. It was stated that a training package has been devised, but the training has not been passed down to staff to date. This area needs to be addressed in order to provide staff with the skills and knowledge to care for these residents. 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 manager of the home must ensure that when assessing residents for admission to the home these factors are taken into consideration and residents matched to the facilities. There are two working hoists in the home, some sliding sheets and handling belts to assist with manual handling. The inspectors were informed by a resident that the clock had stopped in the dining room. The home should explore techniques to enable residents to remain orientated, as it is important, not only in relation to time, but also date and place etc. It is recommended that reviews are undertaken in respect of signage and decoration of communal areas of the home in relation to the needs of residents with cognitive impairment. Different rooms and areas should look different so the residents with cognitive impairment have their independence promoted and avoid unnecessary difficulties. The parts of the home with the original Abbeydale Nursing Home DS0000024813.V289678.R01.S.doc Version 5.1 Page 11 Victorian features do look different and unique, however other parts of the building could prove difficult to these residents. Improvements in signage and different colours for various areas and doors so that residents can distinguish between them. Abbeydale Nursing Home DS0000024813.V289678.R01.S.doc Version 5.1 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is poor. The judgement has been made using available evidence including a visit to this service. Medication systems were generally adequate. There are some areas that need to be addressed to ensure full compliance with regulations. The care planning system, records and communication of good practice need further development to ensure that residents’ needs are being met. 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 one had not been completed. Others gave vague instructions, were not comprehensive, had not been updated when there were changes in care and some had not been signed or dated by the member of staff drawing them up. There was no indication of involvement of the resident or their representative and they had not been consistently reviewed each month by staff to determine if the plan of care was still appropriate. The new manger is aware of the problems with the documentation and is hoping to introduce new documentation. When this occurs he will need to ensure that staff are provided with some training in the use of it to ensure consistency. Abbeydale Nursing Home DS0000024813.V289678.R01.S.doc Version 5.1 Page 13 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, but there was no evidence of visits by other health professionals such as chiropodist, dentist and optician. The manager must ensure that all residents have the opportunity to see these health professionals on a regular basis and it is recorded in their records. If the service is refused it should also be recorded. The inspectors could not evidence records to demonstrate the residents with chronic diseases such as diabetes; asthma and high blood pressure etc. were receiving regular health checks. Nurses were checking diabetic residents blood sugar twice a day, but guidance indicates that they should have regular blood tests undertaken and the new manager was in the process of consulting G.P’s about this. During the inspection it was noted that staff were completing turn charts and fluid charts on a regular basis to demonstrate the care provided. Bed rails were not sufficiently high enough on some beds due to pressure relieving equipment. Stability of bed safety rails with overlay mattresses in place was poor in some instances. The home must contact the manufacturer to determine if any action can be taken to improve this. Poor stability could lead to problems with entrapment. A single use syringe was being re-used with PEG feeds and there were no clear instructions for the use of multiple use syringes. It was noted that some residents who were receiving PEG feeds were not propped sufficiently upright when feeding was in progress. This was discussed with the new manager and he was trying to obtain a special bed for one of the residents. All staff should be made aware of the correct positioning of residents when artificial feeding is in progress in order to prevent complications. On inspection of one file it was noted that the manual handling assessment for one resident stated the hoist should be used, but daily records indicated that the handling belt had been used. All staff should be made aware of the moving and handling requirements for each resident and systems must be in place to ensure they are followed for staff and residents safety. Following a recent audit by the tissue viability nurse the home is in the process of purchasing some new mattresses and have plans to purchase a number of new chairs to meet residents needs. The tissue viability nurse was visiting at the time of inspection and gave positive feedback to the inspector. She stated she found the staff welcoming; the same nurse, who escorted her on visits would go into the home on her day off if she knew the tissue viability nurse was visiting, in order to maintain consistency in care. Staff obtain the appropriate dressings, ensure all instructions are carried out and inform her of any problems. A number of residents have also been referred to the occupational therapist for specialist chairs and physiotherapy as a result of the audit. Training in respect of tissue viability and nutrition has also been given to staff. It was pleasing to receive such positive comments about the staff and Abbeydale Nursing Home DS0000024813.V289678.R01.S.doc Version 5.1 Page 14 to see the way they have embraced the training and changes required to make improvements in this area. The new manager has stated that he is also changing the system regarding the management of catheter bags in order to reduce the incidence of infection. At the time of the last inspection a number of wheelchairs had been purchased. It was not clear that residents had been assessed for wheelchairs. All residents should be assessed for their own wheelchair to ensure it is suitable for the individuals needs. The home uses a monitored dosage system of medication, which is stored appropriately. On inspection of the medication charts (MAR) the administration and recording was found to be fairly satisfactory. The home photocopies prescriptions and it is recommended that they are stored with the relevant MAR chart. Areas that require attention include: • One MAR chart did not indicate the month of administration • The timing of some medication had been changed, but this had not been changed with the G.P. • Rectal diazepam was prescribed, but there was not protocol for it use. • The dose of one medication had been changed and the date was not indicated on the MAR chart. • A resident was receiving liquid medication through a feeding tube and there were instructions to revert to tablets when the bottle of medication was finished. Liquid medication should be given through feeding tubes wherever possible. The manager will need to liaise with the G.P. • Medication was being administered through PEG feeds and there were no instruction about the administration from the drug companies for staff to follow. • “F” had been recorded on one chart to indicate that the home had no stock. However it was recorded as having been administered on two occasions. • There is no system for checking medication details of residents who are admitted from home. • One resident self-administers medication and a risk assessment had been undertaken, but there was no evidence of any monitoring system. At the time of inspection it was also noted that the home did not have a supply of bins for disposal of medication and new suction apparatus had been purchased, but staff were not aware of how to use it. On discussion with some resident’s they stated they were well looked after and staff were good. However, one resident stated they would like to have more frequent baths. There is a telephone in the reception area and a hand held set when privacy is required. At the time of inspection it was noted that some staff did not knock Abbeydale Nursing Home DS0000024813.V289678.R01.S.doc Version 5.1 Page 15 residents or toilet doors before entering, there was a notice about a residents catheter care on display in his bedroom, bibs were being used at meal times. These areas were discussed with the proprietor and managers and it was suggested that practices be reviewed in order to enhance privacy and dignity for residents. Abbeydale Nursing Home DS0000024813.V289678.R01.S.doc Version 5.1 Page 16 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is poor. The judgement has been made using available evidence including a visit to this service. The meals offered are of an adequate standard, but areas in respect of timing of meals, choice and menu planning need to be reviewed. Arrangements for stimulation of residents are poor despite the home now obtaining information about past lives. The system needs to be reviewed to ensure this information is used constructively and residents are stimulated and motivated. EVIDENCE: Residents are free to come and go as they wish and visiting is flexible. 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, who has undertaken a oneday training course. They are employed to work between 11am and 3pm four days a week. The activities co-ordinator has recently been compiling information about residents with a newly used form called “getting to know you”, which was positive. However, it appeared that the information obtained on the form was not used to influence the care or activities arranged in the home. There was a monthly plan of activities on the notice board, which includes shopping and visiting places of worship regularly plus library and Abbeydale Nursing Home DS0000024813.V289678.R01.S.doc Version 5.1 Page 17 summer fete, plus twice weekly visits from progressive mobility, which many of the residents get involved with and enjoyed. She stated there were craft sessions and residents spent time in the garden during the summer. However, there was no evidence of this and the garden has limited accessibility to residents. During the inspection the activities co-ordinator was observed reading to residents. She stated birthdays are celebrated and the home purchases a birthday card and cake. Christmas is celebrated, but none of the other religious festivals such as Easter, Diwali etc are celebrated The manager will need to undertake a comprehensive review of this area and ensure assessments of residents past interests/hobbies is undertaken, they are consulted about a range of activities both inside and outside the home and a plan drawn up to meet residents needs. Then resources must be available to ensure that plans are put into action and records are maintained. The home employs separate catering staff who provides three full meals per day. There is a four-week rotating menu, which provides a choice at lunchtime. There is also an Afro Caribbean and Asian option and Halal meat available to meet the needs of residents from minority groups. It was stated that residents were consulted about choices on the day prior to serving the meal, but on discussion with some residents they stated that choices were offered sometimes. On inspection it was noted that the Halal meat was not labelled clearly when stored and rice for one of the Afro Caribbean meals was cooked on the day before serving, which is not good practice in respect of food hygiene. A system of recording types of meat needs to be introduced and it is recommended that menus should be reviewed with residents to ensure meals are not cooked the day before serving. There are a number of residents who require a soft/liquidised diet and need assistance with feeding by staff and they are usually attended to at the first sitting at lunchtime. A second sitting follows this for the remaining residents. On discussion with residents they stated they enjoyed the meals. The inspector had lunch with residents. Staff were observed to offer discreet assistance, but feeding two residents simultaneously is not good practice. At lunchtime it was noted that meals were plated in the kitchen and were on a trolley in the dining room waiting to be served. Therefore meals were not being served at an appropriate temperature. This must be reviewed and a hot trolley provided for meals if necessary to maintain meals at the appropriate temperature before serving. It was noted that a number of residents were sitting in the dining room waiting for breakfast from 7.30am and they had not received a hot drink. Breakfast was served at about 8.15 am, but residents were not offered any choices and they did not receive a hot drink until approximately 8.30 am. Abbeydale Nursing Home DS0000024813.V289678.R01.S.doc Version 5.1 Page 18 Changes have been made since the last inspection as concerns were raised about the amount of time residents had to wait for breakfast. However, there are still some issues that need to be addressed and it is recommended that a further review of meals times be undertaken in consultation with residents. At present the home uses mainly frozen vegetables, consideration must be given to using fresh ingredients to ensure that the food served is wholesome, balanced and nutritious to meet resident’s needs and preferences. All residents will not like frozen or tinned vegetables and will prefer fresh as this has a different taste, texture and appearance. The home retains a comprehensive record of food taken by residents who experience some problems. However, other records in the kitchen lacked detail, were only in relation to the food ordered and did not provide sufficient detail to determine whether the diet was sufficient to meet residents needs e.g. in regards to quantity eaten. According to staff menus had not been reviewed for approximately one year. The menus did not demonstrate any seasonal variation and this was discussed with the management team. Seasonal alternatives bring a certain amount of variety. On discussion with residents they stated they enjoyed the meals Abbeydale Nursing Home DS0000024813.V289678.R01.S.doc Version 5.1 Page 19 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is poor. The judgement has been made using available evidence including a visit to this service. The procedures in place for complaints and adult protection failed to demonstrate that concerns had been addressed fully; therefore, residents may not be fully protected. EVIDENCE: The inspector did not see the homes procedures in respect of complaints or protection from abuse. On discussion with the manager he showed the record of complaints and none had been recorded. However, on discussion with some residents they stated they were not aware of the procedure for making complaints and issues were raised with the inspectors about missing laundry, items removed from residents rooms without their permission and creams that were not applied regularly by staff. It was stated that staff had been made aware of these concerns, but no action had been taken. It was concerning that residents’ complaints were not being addressed by staff in the home. The manager must ensure that all staff are aware of the procedures to follow when any concerns are raised. In addition, residents and relatives are informed of the procedure for raising any concerns. Clear records must be maintained to include the nature of the complaint, the investigation, the findings, the outcome and resolution. The adult protection procedures were discussed with some staff and the responses were variable, suggesting that some staff are not aware of the action to take in the event of any allegation of abuse. The manager must Abbeydale Nursing Home DS0000024813.V289678.R01.S.doc Version 5.1 Page 20 ensure that all staff receive training in respect of adult abuse and whistle blowing procedures to ensure residents are adequately protected. Abbeydale Nursing Home DS0000024813.V289678.R01.S.doc Version 5.1 Page 21 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 23, 24, 25, 26 Quality in this outcome area is poor. The judgement has been made using available evidence including a visit to this service. The home is furnished to basic standards and a considerable amount of redecoration and maintenance is required. There are many requirements that need to be addressed in order to provide a more homely and safe environment for residents. EVIDENCE: On arrival it was noted that the exterior of the building requires decorating and a number of window frames need replacing. This has been outstanding for some time now and on discussion with the proprietor she stated the work was to be carried out later in the year when the weather improves. On the second day of the inspection a builder was observed around the home and the inspectors were informed they were looking at the external aspects of the home. The damaged stained glass window to the front door had been repaired by placing a half a pane of clear glass over it. In order to gain access through the front door there are a number of steps. The home will need to provide Abbeydale Nursing Home DS0000024813.V289678.R01.S.doc Version 5.1 Page 22 suitable access e.g. ramped in order to meet resident’s needs and also the requirements of the Disability Discrimination Act that has recently come into effect. The garden to the rear of the property needs to have work undertaken to enable residents to access it safely, as there are no areas for walking or sitting in the main part of the garden when the weather permits. There is a large imposing reception are on entering the home with a toilet. On both days of the inspection there was noted to be a slight odour in the reception area emanating form this toilet. There is one large lounge that leads into the dining room on the ground floor and a further two small lounges to the rear of the building. However, one of the lounges is poorly arranged as resident’s chairs are facing the wall and there is little room for movement; arrangements for staff observation are poor and there is no call bell in the room. The dining room and lounges were not measured, but do not appear to provide sufficient space for all residents. Previously it was stated that there were plans to increase the communal space and at the time of inspection the proprietor stated they were planning to have a conservatory built. The proprietor has been advised that planning permission is still required for a conservatory as it is a commercial property. A copy of the plans should also be submitted to the Commission for consideration. 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 en-suite facilities has two doors. The home should contact the fire service as to whether the inner door can be removed as this would increase the space and has the potential to improve the area. 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. Screening was not sufficient in some bedrooms to promote privacy and dignity. Call bells were not always available or accessible to residents in some bedrooms. Abbeydale Nursing Home DS0000024813.V289678.R01.S.doc Version 5.1 Page 23 On 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 including the vanity units in some rooms. Some bedrooms did not have lights that could be accessed from beds and some residents complained about the level of lighting in the home, as it did not meet their needs. There were fluorescent lights in some of the communal areas used by residents, which provide harsh lighting and is not homely. A number of areas require re-decoration in the home including communal areas. The home has a maintenance schedule, but there are no details about a re-decoration programme. 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 and some of the hot water from taps was above 43 degrees, which is the level considered safe to prevent scalding. Records did not indicate temperatures and only stated it was satisfactory in all areas. There are a number of toilets and bathrooms in the home, but they are not easily recognisable as they have numbers on the doors, some did not have locks and the doors are not painted, which means that they cannot be cleaned easily. It was noted the cistern in room 112 was cracked and will need replacing plus an electric cable with exposed wires was hanging from over the toilet door in room 110. Assisted bathing facilities are available on the ground and middle floor. Space is limited in the ground floor assisted bathing facility and the home will need to consider replacing this already damaged facility with an alternative such as a flat floor shower. This limited space impacts on privacy and dignity, but has implications for correct manual handling procedures. Bath mats were observed to have mould growing on the underside. Abbeydale Nursing Home DS0000024813.V289678.R01.S.doc Version 5.1 Page 24 Some aspects in respect of infection control are poorly managed e.g. it was noted that some staff were walking around the home with vinyl gloves on. These gloves should be removed and hands washed after dealing with infected material or body fluids. A washbowl was found on the floor in a resident’s room and a yellow bag used for the disposal on infected material was not stored in an appropriate bin. There is only one sluicing disinfector on the ground floor, which was not working and this remains an outstanding requirement from the last inspection. The first and second floor does not have a sluicing disinfector. Each floor should have a sluicing disinfector and racking to store commode pots etc. Currently shelves are available and these are not considered good practice. The first floor sluice room has a toilet and the proprietor stated that it is not used. This should be removed so that temptation to use it is eliminated. Sluices did not have clinical waste bins and hand-washing facilities were variable. The home needs to review the system in relation to liquid soap, as there were two systems in operation. It is recommended that the home have an audit undertaken by the Health Protection Unit to help them with issues in respect of cross infection. The laundry walls have been painted, but the floor needs to be covered with an impermeable material. The laundry has a sluice sink. This should be removed and a hand-washing sink put in its place. This removes the temptation for staff to sluice items of laundry out, which is not necessary as both machines have a sluice cycle. There are two tumble dryers, but one was not connected and urgent action will need to be taken to address this. Since the inspection the manager has informed the Commission that the tumble dryer has been fitted and is now in working order. 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 home was in the main clean and staff demonstrated a good knowledge of cleaning and hygienic practices. 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; dried lentils and peas were still in their original packaging after opening. These should be stored in airtight containers after opening. Mildew/algae was observed on the window frames and needs removing. At present there are two household domestic fridges and space is limited and frozen meat was being defrosted in the kitchen. This should be defrosted in a fridge and a commercial fridge needs to be purchased for the kitchen to provide sufficient space. Abbeydale Nursing Home DS0000024813.V289678.R01.S.doc Version 5.1 Page 25 Staff wash crockery etc and place it in a rinser. The proprietor was asked to forward the manufacturers details as to the temperatures attained by the rinser as it needs to be a minimum of 85 degrees for food hygiene control. If this temperature is not achieved an alternative must be obtained. COSHH data sheets were available in the kitchen, but no risk assessments had been completed. Kitchen staff also need to carry out Hazeps analysis for food preparation. If these had been completed it would have identified the previous problem in relation to cooking rice the day before serving. Abbeydale Nursing Home DS0000024813.V289678.R01.S.doc Version 5.1 Page 26 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is poor. The judgement has been made using available evidence including a visit to this service. The staff group are very pleasant and have potential to develop their skills and knowledge with training. There have been improvements in the recruitment procedures, but further developments are required to ensure a fully robust system. The number of staff available in the afternoon/evening is not sufficient to meet the needs of residents and a range of staff training is required. EVIDENCE: A new manager had taken up post approximately one week prior to the inspection and the home had been without a manger for approximately two months prior to this. The manager works five days per week of which four will be supernumerary. At the time of inspection rotas indicated there were two nurses and four care staff on duty during the morning; two nurses and three care staff on duty during the evening and one nurse and three care staff on duty overnight. Although the morning and night staff levels meet the minimum standards the evening staffing levels drop below the minimum levels. The home has a number of highly dependent residents and there are a number who require assistance with feeding. The staffing levels for the evenings will need to be increased in order to meet resident’s needs. This area will need to be constantly monitored and staffing adjusted where necessary to meet resident’s needs. On discussion with residents they stated the home was good Abbeydale Nursing Home DS0000024813.V289678.R01.S.doc Version 5.1 Page 27 and staff were always busy. At the last inspection feedback from the quality questionnaires indicated that staff are stretched at times. In addition to care staff there are domestic, catering, laundry activities and maintenance staff. A small sample of staff records were inspected in order to review recruitment procedures and it was found that the home were undertaking POVA checks on staff before they commenced employment and the PIN number of a recently employed nurse had been checked. However, there was no evidence to indicate that gaps in employment on application forms had been checked, all application forms had not been completed or signed, references had been obtained form relatives and colleges and a member of staff who had a student visa did not have any evidence of the course they were undertaking. It was also noted that he had worked in excess of 20 hours each week the previous month. The proprietor made changes to the following months rota to rectify it, however all senior staff must be aware that staff with a student visa must not work in excess of 20 hours per week during term time. The home does have an induction programme for new staff and a copy was shown to the inspectors, although completed copies were not seen in staff files Although the programme covers a number of areas it does not meet the standards of the Skills Council standards, which now covers the first 12 weeks of employment and forms a foundation for NVQ training. The manger will need to review this and ensure that the induction training meets the Skills Council Standards and well as local requirements. The information provided by the senior staff in the home indicated that at least 50 of care staff had undertaken NVQ level 2 training, but there was no evidence to support this. Evidence of all training must be available in the home to demonstrate training that has been undertaken by staff. Abbeydale Nursing Home DS0000024813.V289678.R01.S.doc Version 5.1 Page 28 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 38 Quality in this outcome area is poor. The judgement has been made using available evidence including a visit to this service. The quality assurance system needs to be developed further and systems put in place to address issues raised to ensure an approach of continuous improvement. Action needs to be taken to manage resident’s monies in a more open and accessible manner. The prompt servicing of equipment and provision of training to staff in basic areas could enhance Resident’s health safety and well-being. EVIDENCE: A new manager took up post approximately one week prior to the inspection. He displayed good clinical knowledge and appeared enthusiastic to make improvements. Abbeydale Nursing Home DS0000024813.V289678.R01.S.doc Version 5.1 Page 29 The home has a quality assurance system, which was inspected at the last inspection and it was stated that no further work had been undertaken in this area since then. At that time 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 and audit 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 residents. The last record seen of a residents meeting related to May last year. It was stated that visits were made on behalf of the proprietor and a report was written. These records must be forwarded to the Commission in line with the regulations. Formal staff supervision has recently been undertaken for a small number of staff and records were available in the nurse’s office on the ground floor. Formal supervision should be undertaken at least six times a year by staff who have been trained in this area and records should be stored confidentiality. It should cover all aspects of care, philosophy of care, career developments, welfare and any other issues raised. 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. 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 paying for a taxi and escort to the hospital or health centre. 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. The records in respect of maintenance and servicing were inspected and some areas had been addressed. The following remain outstanding: • There was no evidence of servicing of the call bell system • Testing had been undertaken for legionella, but chlorination of the tanks had not been undertaken. The home has since provided information that the tanks have been treated. Abbeydale Nursing Home DS0000024813.V289678.R01.S.doc Version 5.1 Page 30 • • • • • • • • There was a gas safety certificate for some gas appliances, but not for the kitchen equipment. Following the inspection a gas safety certificate was forwarded to the Commission for the kitchen equipment Evidence that the electrical wiring system has been checked was forwarded to the Commission since the inspection. . There was no evidence that the scales had been tested and calibrated. The in house checks of hot water temperatures did not indicate the temperature of the water at outlets and there was no evidence to demonstrate that the water had been run from outlets that were not in use. Issues were raised at the last fire officer’s visit and there was no evidence to demonstrate that they had been addressed. Risk assessments in respect of fire, chemicals, environment and shoes worn by some staff need to be undertaken. Staff were observed to be wearing incorrect footwear. One fire extinguisher was not firmly attached to the wall Training records were not comprehensive and certificates were not available to demonstrate when training had taken place. Some certificates available were in relation to staff who were no longer working in the home, It could not be demonstrated that all staff had undertaken the core training e.g. fire prevention and fire drills, basic food hygiene, first aid, manual handling and infection control. On discussion with some staff they were not fully aware of the fire procedure. Manual handling training had lapsed for staff and the inspector were informed that the activities co-ordinator had undertaken an accredited manual handling trainers course, but was unable to undertake training at present as she had not received her certificate. A copy of this should be forwarded to the Commission, as on further discussion and analysis post inspection it appears that the training was for one day only. An accredited trainers course for manual handling usually lasts between 3 and 5 days. It is recommended that the manager undertake a training audit and draw up a template indicating the date any training has taken place with appropriate evidence. Then a plan of training drawn up should be drawn up to ensure all staff undertake the appropriate training. Abbeydale Nursing Home DS0000024813.V289678.R01.S.doc Version 5.1 Page 31 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 X X 1 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 1 1 1 1 X 2 1 1 1 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 2 1 X 2 Abbeydale Nursing Home DS0000024813.V289678.R01.S.doc Version 5.1 Page 32 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 OP3 Regulation 14 Requirement Timescale for action 30/07/06 2 OP4OP7 14 3. OP4 12(1) 18(1) 4. OP4 12(1) 13(4) The registered person must ensure a comprehensive assessment is undertaken for all residents before entering the home and write to them or their representatives to confirm if the home is able to meet their needs. The registered person must 30/07/06 ensure that a comprehensive assessment is undertaken for all residents to include a mental health assessment, continence assessment, manual handling assessment, general risk assessment and ensure conflicting statements are not made. The registered person must 30/09/06 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 30/05/06 facilitate a suitable system for residents with dementia to be able to call for assistance or alert DS0000024813.V289678.R01.S.doc Version 5.1 Abbeydale Nursing Home Page 33 5. OP7 15 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 all the residents needs and must be specific to the needs • The process must include consultation with the resident or their relatives. • Care plans must be reviewed monthly and updated where there are any changes. Timescale of 30/8/05 not met. 30/07/06 6. OP8 13(1) 7. OP8 12(1) The registered person must: • Have systems in place to ensure that care plans are implemented and they are audited on a regular basis. • Training should be given in the new care planning system. The registered person must 30/05/06 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, hypertension asthma, etc are reviewed on a regular basis by a health professional and records are retained in the home. Timescale of 30/12/05 not met. The registered person must: 30/05/06 Ensure that all residents who require a wheelchair are referred for an appropriate assessment. Timescale of 30/11/05 not met. • Abbeydale Nursing Home DS0000024813.V289678.R01.S.doc Version 5.1 Page 34 8 OP8 12(1) 18(1) 12(1) 9 OP8 10 OP8 12(1) 11 OP8 12(1) 12. OP8 12(1) 13. OP9 13(2) Contact the manufacturers re stability when using bed rails and over lay mattress to determine if there is anything that can be done about the situation. The registered person must ensure that all staff undertake training in respect of continence management. The registered person must ensure that all staff are aware of the manual handling requirements of residents and systems are in place to ensure staff follow instructions. The registered person must ensure: • All syringes for single use are disposed of after use. • Multiple use syringes and cleaned and dried properly between uses. The registered person must ensure that all residents are consulted about their preferences in respect of bathing and ensure systems are in place to meet their needs/preferences. The registered person must ensure that all residents are weighed on admission and at regular intervals afterwards. The registered person must ensure a robust system for medication to include: • The accurate administration and recording of medication. • Ensure systems are in place so that the home does not run out of medication. • Ensure there are clear records to indicate when the dose of medication is changed. DS0000024813.V289678.R01.S.doc 30/06/06 15/05/06 10/05/06 10/05/06 10/05/06 25/05/06 Abbeydale Nursing Home Version 5.1 Page 35 14 OP10 12(4) 15. OP12 16(2)(m) (n) 14 16. OP15 17(2) Timescale of 5/11/05 not met. • Ensure all MAR charts are clearly dated. • Liaise with the G.P. where times of mediation are changed. • Draw up a protocol for the administration of rectal diazepam. • Ensure there is a system in place for checking resident’s medication when they are admitted to the home. • Ensure there are systems in place for monitoring residents who are selfadministering medication. • Contact the information department of drug companies for advice regarding the administration of drugs via the PEG tube. The registered person must 10/05/06 review systems and take action to ensure residents privacy and dignity is respected to include; staff knock on residents door before entering, notices re aspects of care must not be on display. The registered person must 30/06/06 undertake a review of the arrangements for stimulation of residents and activities to include an assessment of residents past interests and hobbies, they are consulted about any activities. Following this a plan is drawn up for group and individual activities to meet all their needs and arrangements are put in place to implement and record them. Timescale of February 2003 not met. The registered person must 15/05/06 ensure the record of food for all DS0000024813.V289678.R01.S.doc Version 5.1 Page 36 Abbeydale Nursing Home 17. OP15 16(2)(i) 12(4) 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. Timescale of 15/11/05 not met. The registered person must incorporate some fresh vegetables into the main meals. Timescale of 30/6/05 not met. The registered person must ensure: • Residents are offered choices in respect of meals and a hot drink in the morning. • All meals are served at the correct temperatures. • 15/05/06 18. OP16 22 All foods that a stored are clearly labelled including meat. • Review the menus in consultation with residents The registered person must 20/05/06 ensure; All concerns/complaints are taken seriously. A record of all concerns/complaints is held in the home indicating the nature of the complaint, investigation, outcome and resolution. Timescale of 30/11/05 not met. Staff are trained in the correct procedures for responding to any concerns/complaints Residents and relatives are informed of the procedures for raising concerns/complaints. The registered person must ensure all staff are provided with training in respect of adult DS0000024813.V289678.R01.S.doc 19 OP18 13(6) 30/05/06 Abbeydale Nursing Home Version 5.1 Page 37 20. OP19 23(2)(b) 21 OP19 23(2)(b) 22 OP19 16(2)(j) abuse, the procedures for responding to any allegations including the whistle blowing procedure. The registered person must undertake and audit of the exterior of the home replace damaged windows and cladding and re-decorate. Timescale of 30/10/05 not met. The registered person must ensure the garden area is made suitable for residents to use when weather permits e.g. areas to walk and sit The registered person must ensure: Adequate refrigeration space is available in the kitchen. Provide the Commission with information regarding the rinser in the kitchen to determine the temperatures achieved. The registered person must provide suitable ramped access to the front of the building in order to meet residents needs and DDA The registered person must provide plans with timescales for extension to the communal space. Timescale of May 2004 not met. The registered person must ensure appropriate safety locks are fitted to all toilet and bathroom doors to indicate when in use, but can be accessed in the event of an emergency. Timescale of 30/8/05 not met. The registered person must review the bathing facilities as outlined in the report and take appropriate action to provide facilities to meet residents needs and ensure health and safety guidelines are met DS0000024813.V289678.R01.S.doc 30/08/06 30/06/06 15/06/06 23. OP19 23(2)(n) DDA 30/08/06 24. OP20 23(2)(g) 30/07/06 25. OP21 12(4)(a) 30/05/06 26 OP21 23(2)(j) (n) 30/07/06 Abbeydale Nursing Home Version 5.1 Page 38 27 OP21 13(3) 28. OP22 23(2)(n) 29. OP23 23(2)(e) (f) 30. OP23 23(2)(d) 31. OP24 16(2)(c) 32. OP24 12(4)(a) The registered person must; Replace the cracked cistern in room 112. Make safe the exposed wires in room 110 Paint bathroom and toilet doors to enable easier recognition and cleaning. The registered person must ensure a call bell is available in the small lounge used by residents. Timescale of 30/11/05 not met. The registered person must provide information as to when the small double room will revert to a single room. Timescale of 30/7/05 not met. The registered person must 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. DS0000024813.V289678.R01.S.doc 30/05/06 30/05/06 30/06/06 30/07/06 30/06/06 30/06/06 Abbeydale Nursing Home Version 5.1 Page 39 33. OP24 16(2) 34 OP25 12(4) Timescale of 30/9/05 not met. The registered person must Provide a minimum of 2 double electrical sockets in each bedroom. Provide an action plan. Timescale of 30/7/05 not met. The registered person must undertake an audit of all privacy curtains ensuring the rails are safe and the curtains extend around the circumference of the bed. Timescale of 19/1/06 not met. 30/06/06 30/05/06 35. OP25 23(2)(p) The registered person must; Audit all radiators and ensure they can be adjusted by residents and re covered. Ensure hot water from all outlets accessible to residents must be 43 degrees or - 1 degree. Replace fluorescent lighting in communal areas with something more domestic in character. Ensure all lights have shades fitted and are accessible from 30/06/06 Abbeydale Nursing Home DS0000024813.V289678.R01.S.doc Version 5.1 Page 40 36. OP26 13(3) resident’s beds. Timescale of 30/7/05 not met. The registered person must: Ensure the laundry floor is replaced with a suitable alternative that is impermeable. Provide dedicated hand washing facilities in all areas where clinical waste or infected materials are handled. Timescale of 30/8/05 not met. The registered person must review the laundry system and address any issues to ensure all residents clothing is returned to them in a timely manner. Timescale of 30/11/05 not met. The registered person must ensure there are good systems in respect of infection control to include; Staff must remove gloves and wash their hands after dealing with infected materials or incontinence. Washbowls must be stored appropriately after use. Yellow bags for use with infected materials must be housed in an appropriate bin. Bath mats must be thoroughly cleaned after use. The registered person must ensure a sluicing disinfector is available on each floor that is in working order with appropriate racking and hand washing facilities in each sluice. 30/05/06 37. OP26 12(1) 30/05/06 38 OP26 13(3) 30/05/06 39. OP27 18(1) The registered person must ensure the staffing levels are DS0000024813.V289678.R01.S.doc 30/05/06 Abbeydale Nursing Home Version 5.1 Page 41 increased to provide at least a ratio of 1 member of staff to five residents during the day. If they wish to vary the staffing levels a formal written proposal must be made to the Commission following a staffing audit. 40 OP28 18(1) The registered person must 30/10/06 ensure that at least 50 of care staff have completed NVQ level 2 and records are available in the home for inspection. All staff files must clearly 30/05/06 indicate the following information; • Full name, address, date of birth, qualifications and experience. • The date employment commenced and ceased. • The position held in the home, the work performed and the number of hours employed. The registered person must ensure a robust recruitment procedure to include; Two written references from previous employers Check all gaps in previous employment Staff must not work in excess of any restrictions placed on them e.g. students The registered person must ensure a robust recruitment procedure to include; Two written references from previous employers Check all gaps in previous employment Staff must not work in excess of any restrictions placed on them e.g. students The registered person must ensure all staff undertake DS0000024813.V289678.R01.S.doc 41 OP29 17(2) 19 42. OP29 19 30/05/06 43. OP30 18(1) 30/09/06 Abbeydale Nursing Home Version 5.1 Page 42 44. OP31 8 45. OP33 24(2)(3) induction training to Social Skills Council standards within 12 weeks of commencing employment. Timescale of 30/8/05 not met. The responsible individual must forward an application to the Commission for registration of the manager. 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. Where any issues are identified from feedback there must be appropriate mechanisms to address the issues and provide evidence of the action taken. Timescale of 30/9/05 not met. The registered provider must undertake a visit to the home each month, write a report, which is signed, leave a copy with the home and forward a copy to the Commission. Timescale of February 2003 not met. The registered person must ensure all resident’s money is deposited in an account, which bears the names of residents. 30/07/06 30/10/06 46. OP33 26 30/05/06 47. OP34 20 17(2) 30/05/06 48. OP36 18(2) There must be two signatures for all transactions made on behalf of residents ideally one being the residents. Timescale 15/12/05 not met. 30/06/06 The registered person must ensure that systems are in place where staff receive formal supervision at least six times a year by a person who has undertaken training in this area. The process must cover all areas outlined in the standards and DS0000024813.V289678.R01.S.doc Version 5.1 Page 43 Abbeydale Nursing Home 49. OP38 23(4)(d) (e) 50. OP38 18(1) 51. OP38 13(4) 52 53 OP38 OP38 13(4) 23(4) 54 55 OP38 OP38 13(4) 13(4) records must be retained in a confidential manner in the home to demonstrate this. Timescale of 30/12/05 not met. The registered person must ensure all staff undertake 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 basic training in respect of basic food hygiene, infection control, first aid plus moving and handling and records must be retained home. Timescale of 30/12/05 not met. The registered person must ensure the following servicing is undertaken and records are retained in the home: Call bell system Timescale of 30/1/06 not met. The registered person must ensure servicing and calibration of the weighing scales. The registered person must provide evidence that the issues identified in the fire officer’s report have been addressed. The registered person must undertake risk assessments in respect of chemicals and fire The registered person must ensure records of the water temperature of hot water taps is recorded when checked. A record is maintained when the water is run from taps that are not in use regularly. 30/05/06 30/07/06 30/05/06 30/05/06 30/05/06 15/06/06 20/05/06 Abbeydale Nursing Home DS0000024813.V289678.R01.S.doc Version 5.1 Page 44 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 Refer to Standard OP3 OP3 Good Practice Recommendations It is recommended that the assessment tool for manual handling and continence is reviewed and training provided where appropriate. It is recommended that the manger liaise with social workers to obtain a copy of the assessments they have undertaken for all residents admitted to the home. (Carried forward) The registered person must undertake a review of the equipment used for moving and handling in the home and provide any further equipment required. It is recommended that the home provide suitable equipment for orientation of residents and take advice about colours etc when decorating the home. It is recommended that the photocopies of prescriptions be retained with the relevant MAR chart. (Carried forward) The registered person should contact the Health Protection Unit 0121 224 4722 to discuss an infection control issues with a view to having an audit undertaken. It is recommended that a training needs analysis be undertaken for all staff and a plan of training drawn up. (Carried forward) The manger should inform the PCT and Social Care and Health where any resident is admitted to hospital. (Carried forward) 3 4 5. OP4 OP4 OP9 6 7. OP26 OP38 8. OP38 Abbeydale Nursing Home DS0000024813.V289678.R01.S.doc Version 5.1 Page 45 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. Extracts may not be used or reproduced without the express permission of CSCI Abbeydale Nursing Home DS0000024813.V289678.R01.S.doc Version 5.1 Page 46 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!