Inspection on 30/04/07 for Abbeyfield

This inspection was carried out on 30th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

Abbeyfield 26/01/06

Abbeyfield 19/07/05

Abbeyfield 08/02/05

Abbeyfield 14/09/04

Abbeyfield 04/03/04

Similar services:

St Vincents

The Cotswold Home

Winton House

Newbeech House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Abbeyfield 11 Maitland Road Reading Berkshire RG1 6NL Lead Inspector Delia Styles Unannounced Inspection 30th April 2007 10:30 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 Abbeyfield DS0000011074.V337703.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Abbeyfield DS0000011074.V337703.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbeyfield Address 11 Maitland Road Reading Berkshire RG1 6NL 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) 0118 957 2826 0118 959 4867 Abbeyfield Reading Society Limited Mrs Bernadette Yanquoi Care Home 28 Category(ies) of Old age, not falling within any other category registration, with number (28) of places Abbeyfield DS0000011074.V337703.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th January 2006 Brief Description of the Service: Abbeyfield House provides care and accommodation to residents whose needs are associated with old age. The home is run by a voluntary organisation the Abbeyfield (Reading) Society, through a locally run committee. The Society is a member of the National Abbeyfield Society who provide co-ordination and back-up services. The Abbeyfield Society is a Christian based organisation. The home was opened in 1996 and purpose built. It is situated one mile from Reading town centre. There is a small public park at the rear of the garden. An Anglican church is opposite the house. There are 28 single rooms, each with an en-suite w.c and hand basin, built-in wardrobe, TV, and telephone point (if required). Basic furnishings are provided although residents are encouraged to bring some pieces of their own. In addition to the main lounge, there is a quiet lounge and a dining room. There is also a conservatory on the ground floor that leads out to a landscaped garden. The current range of fees is between £540 and £610 per week Abbeyfield DS0000011074.V337703.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection of Abbeyfield House was an unannounced ‘Key Inspection’. The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standard of the service. The inspector arrived at the service at 10.50 am and was in the service for 5.5 hours. It was a thorough look at how well the service is doing. The inspector took into account detailed information provided by the manager, and any information that CSCI has received about the service since the last inspection. The inspector asked the views of the people who live here and other people seen during the inspection or who responded to questionnaires that the Commission had sent out. A total of 3 questionnaires were returned from residents (completed with the help of relatives); 6 from relatives, and one from a GP who provides medical care to some of the residents. The inspector would like to thank the residents, managers and staff for their welcome, time and assistance during the inspection. What the service does well: The home provides a warm and friendly atmosphere and there is a good sense of community and support between residents and staff. Residents’ and relatives’ comments were very positive about the qualities of the staff and the care they provide, for example: ‘The staff are extremely kind and patient. . There is a very happy atmosphere at all times I am there’ ‘All the helpers at Abbeyfield have a very kind and caring approach to those in their care’. ‘The home looks after people with dignity’. The home organises regular outings for residents and these are much enjoyed. Food and mealtimes are good – ‘the food looks appetising and varied, giving a choice of menu.’ ‘The meals and snacks are excellent’. Residents and their families are encouraged to be involved in the running of the home, fund raising events and social occasions. Abbeyfield DS0000011074.V337703.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can Abbeyfield DS0000011074.V337703.R01.S.doc Version 5.2 Page 7 be made available in other formats on request. Abbeyfield DS0000011074.V337703.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Abbeyfield DS0000011074.V337703.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. Standard 3 does not apply, as the home does not provide intermediate care. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The standard of written information about this home is good but improvements should be made to the pre-admission and admission procedures and the written needs assessment records for residents so that they are sufficiently detailed and enable staff to build up accurate plans of care for each individual. EVIDENCE: The home has a good range of written information that is provided to prospective residents before they move into the home. Two residents spoken with could not recall having received written information about the home, though one person remembered that they had a copy of the home’s ‘Residents Handbook’ in their room. Neither could recall the name of the ‘key worker’ who has special responsibility for ensuring that their care needs are being met. Abbeyfield DS0000011074.V337703.R01.S.doc Version 5.2 Page 10 The written assessment of needs seen for these residents was incomplete, for example risk of falls, mobility, and continence assessment were not evident. From conversation with the managers it was clear to the inspector that that they had a good level of knowledge about the residents’ needs, but this was not available in sufficient detail for staff to base their care plans on. It is important that all prospective residents have a full assessment of needs and especially where individuals are self-funding and do not have care management (health and social services) assessment, so that the home’s staff can demonstrate that they will be able to meet the needs of the residents. Abbeyfield DS0000011074.V337703.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of written records of care is poor and does not reflect the good standard of care provided by staff in practice. Residents’ plans of care should be sufficiently detailed, kept up to date and have any changes agreed with the resident or their representative, so that the home can demonstrate that residents’ health and personal care needs are fully met. The homes policies and procedures for medication administration and staff training are good overall but some ‘best practice’ improvements are recommended to further safeguard residents from medication errors or misuse. EVIDENCE: The inspector looked at a sample of 3 resident’s care records – two recently admitted, and one person who has lived in the home for some years. Each resident has an individual booklet with detailed sections for staff to record their assessed needs, risks (such as pressure area damage, moving and handling and nutrition) and care plans. There were no care plans as such completed, so that it was not clear to what extent staff have provided care that meets the assessed needs of the residents. Monthly reviews of care were not Abbeyfield DS0000011074.V337703.R01.S.doc Version 5.2 Page 12 completed. Care staff write in separate records – a care plan diary – for each resident. The daily entries in these were non-specific and there was no followthrough or evaluation of recorded problems or significant changes (relating to one resident’s condition). The doctors visit section of the printed booklet are not completed – a record is kept in the carers’ notes, but this does not provide a record of the reason or frequency of medical attention. However, there was evidence from residents and their relatives’ comment cards that indicate that any health needs are addressed quickly and effectively. The home has good communication and support with local GP practices and district nurses. The senior staff member responsible for training and pastoral care acknowledged that the standard of written care records was poor and undertook to take prompt action to help care staff to review and update them. However, she pointed out that care staff do have a generous ‘overlap’ staff handover meeting each afternoon, so that any changes in residents’ care is discussed and in practice, staff are aware of each resident’s needs and provide a high standard of care. The inspector recommends that residents (or their representative) are actively involved in drawing up of their care plans and that they sign and agree these (wherever capable). The proportion of residents living with dementia has increased within the home; some concerns have been raised by relatives in their written comment cards about the impact that this may have for residents and staff, for example – ‘I very much appreciate the hard work the staff give to the home, it is very difficult with the wide range of disabilities of the residents ... the increase of dementia among some residents will create problems with the more mentally alert residents and spoil the relaxed and happy atmosphere and make heavy demands on the present staff’. The managers and care staff have had further training in caring for people with dementia. The homes policies and procedures for the receipt, storage, administration and disposal of unwanted medications are good. The local pharmacist provides staff training to the required accredited standard. Some residents self-medicate; their medications are kept in a separate cupboard in clinical room and the deputy manager in charge of medication checks and signs the list of medication and what has been ordered and the pharmacist will come in and check each resident’s understanding and ability to continue to self-administer. The sample of Medication Administration Record (MAR) charts seen by the inspector was correctly completed. Some charts had handwritten entries made by the staff on the instruction of a doctor. If staff have to add handwritten Abbeyfield DS0000011074.V337703.R01.S.doc Version 5.2 Page 13 instructions to the MAR charts, ideally the doctor who has ordered the amendments should be asked to check and countersign them in person, as soon as possible. Alternatively, a second care staff member should check and sign the first carer’s entry. This is an additional ‘best practice’ safeguard to reduce the risk of error and the potential for residents to be given the wrong medication or dosage. There was no list of the signatures and usual initials of all care staff authorised to give out medication: the home should ensure that they maintain a list of staff signatures so that the MAR charts can be audited and checked effectively. The keys to the medication storage area were held on the same key ring as other keys – this should not be the case, because there is a risk that the master keys could be handed over to staff not authorised to access medicines in the home. The homes records of the drug fridge temperature indicate that the fridge temperature is frequently at or above the upper limit for the recommended safe temperature for medicines requiring cold storage (2-8°C). The fridge was iced up and needed defrosting, which may have accounted for the higher temperature readings. The medication storage room was also very warm – in excess of 25°C – which is above the recommended maximum storage temperature for many medications. The home should look at ways of improving the ventilation in this room to ensure that medicines are kept within the recommended temperature range so that their quality and effectiveness is not compromised. Residents confirmed in their conversation and written comments that they are treated with respect and their dignity is upheld by staff. Abbeyfield DS0000011074.V337703.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a good range of activities and outings outside the home but more limited opportunities for all residents to participate in stimulating and meaningful activities with in the home. The manager is aware of the areas of weakness and has plans to improve the service for less able residents. Residents and their families and representatives are encouraged to play an active role in the social life of the home. Meals and mealtimes are an enjoyable social occasion for residents. EVIDENCE: An activities programme for the week was seen in residents’ individual rooms and on the reception area notice board, with photos of residents enjoying recent outings and social events. A small bus is hired for outings. Residents spoken with were pleased with the opportunities to go out on trips to places of interest. Residents spoken with in their rooms were content with their own pastimes – reading, word puzzles and letter writing. However, 2 written comments from relatives indicate that there is scope for improvement in increasing the activities available on a daily basis for those residents who are physically or mentally more frail: ‘I know they are constantly Abbeyfield DS0000011074.V337703.R01.S.doc Version 5.2 Page 15 trying too have more activities available on a day-to-day basis but need many more volunteers to implement these. Boredom is a very real problem’. ‘There is a good range of outside activities arranged but more in-house activities could possibly stimulate some residents. Especially in the early evening after supper has been served – simple card games etc.’ Though the home cannot accommodate resident’s own pets, most residents appreciate the company of the home’s cat – a large contented tabby. The home encourages residents to maintain contact with family, friends and representatives. Visitors feel welcomed and appreciate the home’s ‘very happy’ and ‘relaxed’ atmosphere. The home ‘seeks to involve friends and relatives in running the home – also in fund raising and receiving hospitality’. Many residents have their own telephone in their room. There is an active Residents committee and a resident representative who sits on the House Committee (a small group of local volunteers, and the manager and her deputy, who meet together monthly) so that the views of residents are represented and conveyed to the Executive committee that has overall responsibility for the running of the home. Residents are appreciative of the quality of the food provided in the home and is considered to be a particularly positive aspect. Written comments and questionnaire responses indicated that meals usually meet people’s expectations: ‘Meals and snacks are excellent’ and ‘the food looks appetising and varied, giving a choice of menu’. The inspector joined residents at lunchtime on the day of the inspection. Lunch was homemade vegetable soup, pork casserole, cabbage, Swede, or bacon & egg quiche; followed by apple crumble with custard, cream or ice cream for dessert. Lemon or orange squash or water was served with meal, and coffee or tea after. Residents were observed to enjoy their meals and were appropriately assisted. All spoken with said the food was very good. As is the case with many care homes, there is more ethnic and racial diversity amongst staff than the current resident group. The homes provider and managers show an awareness and understanding of equalities and diversity for staff and prospective residents. From the evidence seen by the inspector and discussion with the manager, the inspector considers that this service would be able to provide a service to meet the needs of individuals of various religious, racial or cultural needs. Abbeyfield DS0000011074.V337703.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has an open culture and residents feel safe and well supported by staff. The home policies, procedures and staff training ensure that staff have clear guidance about how to safeguard residents from abuse. EVIDENCE: The homes complaints procedure is clearly explained in all the written information about the home, together with the role and contact details of other advocates and services. All the comment card responses indicated that residents and their families felt confident that if they had any complaints, they knew how to make them and were confident that they would be looked into and acted upon by the home management team. The home has not received any complaints and no complainant has contacted the Commission with information concerning any complaint made to the service since the last inspection. All new staff have training in adult safeguarding matters as part of their induction and there are regular update sessions to make sure that staff are alert to, and know how to report any suspected abuse. The home has copies of the local Multi-agency Codes of Practice for the Protection of Vulnerable Adults. All staff are given the General Social Care Council Codes of Conduct Abbeyfield DS0000011074.V337703.R01.S.doc Version 5.2 Page 17 booklet, which sets out the standards of expected of them and employers in relation to protection of people in their care. Abbeyfield DS0000011074.V337703.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of the environment within the home is good providing residents with an attractive, safe and homely place to live. EVIDENCE: The inspector toured the home and visited 2 residents in their rooms. The standard of cleanliness was very good in all the areas seen and there were no unpleasant odours, with the exception of one area, which the manager was aware of and was working to resolve. Some staining was noticed on the pink carpeting of the corridor and landing area. The upper floors are accessible from stairs or a passenger lift. The lift has recently been refurbished and provides a smooth ride, with a fold-down seat for those who wish to sit and an audio message informing residents which floor level has been reached. Laminated signs opposite to the lift doors also show which floor has been reached, for the assistance of residents and visitors. Abbeyfield DS0000011074.V337703.R01.S.doc Version 5.2 Page 19 The communal rooms are bright, airy and comfortably furnished. The home undertakes to provide good quality basic furniture but residents are encouraged to bring in their own small pieces of furniture and possessions. The inspector noted that there was no second chair provided for visitors in the individual bedrooms visited (and was invited to sit on the resident’s bed in both rooms); and in one room, there was no bedside light. The national minimum standards for people’s individual accommodation state that there should be ‘comfortable seating for two people’ and ‘overhead and bedside lighting’. Whilst it is appreciated that recently admitted residents were still in the process of arranging to complete the furnishing of their rooms with their own possessions, the home should ensure that there is provision of the minimum furnishings in the interim. The garden is very attractive, with raised flowerbeds full of pansies (residents had been involved in planting these), and a water feature. There is a ramped pathway into the garden and garden seats around. The conservatory (partly used as an extension to the dining area) is very warm (though blinds screen the roof). The manager said that the Society is considering extending the dining room and moving the conservatory. There is a purpose-built laundry and designated part-time laundry worker. One resident complained that the laundry is ‘very slow in returning clean clothes’. A senior staff member agreed that there had been ‘some problems’ with the laundry recently, perhaps because the home had had to use more agency staff and there had been a change in senior care staff and key workers so that there had been some disruption to the system for ensuring that the correct personal laundry was returned to residents. The home has sluice rooms and staff have supplies of protective clothing and hand hygiene systems that assist them in good practice in the control of infection. Abbeyfield DS0000011074.V337703.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staffing numbers meet the needs of the current residents and the management has plans in place to continue to improve staffing and training for the benefit of residents. EVIDENCE: On the day of the inspection the home manager, deputy manager, a part-time senior staff member, trainee senior carer and 3 care staff, plus the administrative manager, chef and kitchen assistant, and 3 volunteer workers (during the morning) were on duty. The homes own calculations for the allocation of staff numbers and skills according to the dependency of the residents and the staffing rota show that the home provides sufficient numbers of staff to meet the care needs of the residents. The home uses a ‘key worker’ system, whereby individual care staff are ‘matched’ with each resident to ensure that their care is given in the way that best suits the individual and any problems can be discussed with the key worker. This is a very good system, but in practice residents spoken with were not aware of who their key worker was, or their specific role. Consideration should be given to improving the way in which residents are informed about the key worker system. Abbeyfield DS0000011074.V337703.R01.S.doc Version 5.2 Page 21 Questionnaire responses indicated that residents and their relatives and representatives are very appreciative of the staff and feel that there are always staff available to help them. Comments included were ‘It is well staffed with many carers having worked there for several years. The staff are extremely kind and patient, even in the most annoying circumstances’; ‘All the helpers at Abbeyfield have a very kind and caring approach to those in their care’. One questionnaire response showed some concern about the necessity to use agency staff – ‘I hope that every effort is made so far as possible to employ permanent staff with minimal recourse to agency staff’. The manager confirmed that there had been an increase in senior care staff changes because 3 staff had left. However new senior carers had been appointed and the home is actively recruiting more care staff, so that the manager is confident that the staff team will soon be complete. The home also has a small number of ‘bank staff’ who are used to cover staff vacancies. The inspector looked at a sample of 2 files for recently employed staff. Overall the home has a systematic and rigorous approach to recruitment ensuring that the correct checks and vetting of new staff are undertaken so that residents are protected from unsuitable people being employed. There were no interview schedules or evidence of the interview process: it is recommended good practice to keep a record of the date and a summary of the interview questions and the outcome assessment of 2 interviewers, to demonstrate that the home is operating a fair process. Consideration should also be given to ways of involving residents in the recruitment process. Because of staff turnover, the number of staff who have achieved National Vocational Qualification at Level 2 or above remains slightly below the 50 proportion recommended by the Commission. However, the home has a strong commitment to training and there is evidence that staff training targets will be met or exceeded in the near future. Abbeyfield DS0000011074.V337703.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management of the home is effective so that the health, safety and wellbeing of residents are promoted. The managers invite the views of residents and their representatives and act upon them. EVIDENCE: The manager, Ms Yanquoi, is competent and experienced in her role. She had recently completed the Registered Manager’s Award and now has the formal qualifications required of registered manages for care establishments. A deputy manager, and an administrative manager support Ms Yanquoi. There is an active Residents committee and a resident representative who sits on the House Committee (a small group of local volunteers, and the manager and her deputy, who meet together monthly) so that the views of residents are Abbeyfield DS0000011074.V337703.R01.S.doc Version 5.2 Page 23 represented and conveyed to the Executive committee that has overall responsibility for the running of the home. There are regular residents meetings and a resident representative (MS) is on the House Committee. There are comments/suggestions leaflets for residents and relatives to complete in the front reception area, and a photo board of all the House Committee members. The arrangements for the management of personal allowances for residents were seen. The homes administrator maintains a named folder for each resident who is unable or does not wish to maintain control of their own personal allowances, including letters to their Power of Attorney (where applicable). The homes treasurer audits and monitors the system on a regular basis. The current system is transparent and information and records are shared with relevant parties. It is the policy of the organisation that no member of the homes staff can act as an appointee for a resident. In practice all residents have either family members, legal representatives or the local authority to act on their behalf in respect of their financial interests. The health and safety arrangements within the home are well managed and supported by a range of policies and procedures that are regularly updated. The fire safety officer has recently visited the home and there were no reported shortfalls. The homes records show that regular maintenance and safety checks are undertaken by specialist external services as necessary. The inspector looked at a sample of accident records for residents. It is recommended that the home incorporates a ‘body map’ to indicate the location and extent of any skin damage noted as a result of a fall or accident so that staff have a ‘baseline’ observation and can monitor and record any deterioration or resolution of residents’ injuries. The manager confirmed that staff have received First Aid training so that there is always a qualified firstaider on duty. Abbeyfield DS0000011074.V337703.R01.S.doc Version 5.2 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 3 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Abbeyfield DS0000011074.V337703.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO 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. Standard Regulation Requirement Timescale for action 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 OP7 Good Practice Recommendations Improve the detail of residents written pre-admission assessments, to ensure that staff have enough information upon which to base their plans of care. * Improve residents’ plans of care so that they are sufficiently detailed to show the action that needs to be taken by care staff to ensure that all aspects of the health, personal and social care needs of the resident are met. * Care plans should be drawn up with the involvement of the resident and agreed and signed by the resident (or representative) * Care plans should include completed risk assessments with particular attention to the prevention of falls. * Care plans must be reviewed at least monthly and updated to reflect any changes in the resident’s care needs. * There should be evidence of evaluation of care and staff daily statements should refer to and reflect the resident’s DS0000011074.V337703.R01.S.doc Version 5.2 Page 26 Abbeyfield 3. OP9 4. 5. 6. 7. OP12 OP24 OP27 OP29 8. OP38 care needs or ‘problems’ set out in their plan of care. * Maintain a list of the signatures and initials of all staff authorised to administer medication to residents. * If handwritten amendments are made to residents’ MAR charts, these should be checked and countersigned by the doctor as soon as possible; or a second suitably qualified care staff should check and countersign the first carer’s entry. * The temperature of the drug fridge and medication storage room should be monitored and adjusted as necessary, to ensure that medications are stored within the correct temperature range. * Keys for the medication storage area should be kept separate from the master key ring. Increase the range and variety of in-house activities with particular reference to the needs of those residents with dementia and other impairments. Ensure that, in the absence of residents’ own provision, furnishings for individual rooms are provided by the home to the minimum stipulated. Ensure that residents are aware of ‘their’ key worker and the role of a key worker. * Maintain a record of the interview schedule and evidence of the employers’ decision-making process when interviewing prospective staff. * Two or more senior members of staff are present at interviews to reduce bias. * Involve residents in the selection and interview process for new staff. Include a ‘body map’ to document the extent of visible injuries in accident records. Abbeyfield DS0000011074.V337703.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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