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Inspection on 08/06/05 for Abbeyfield Residential Care Home

Also see our care home review for Abbeyfield Residential Care Home for more information

This inspection was carried out on 8th June 2005.

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

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

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

What the care home does well

A resident spoken to, who had recently come to stay in the home, confirmed that it had been a positive choice to move here and that they had received full information about the home and the services provided. The home has caring and enthusiastic staff who enjoy their work. Residents spoken to said that the staff are kind and helpful to them. Relatives are also very impressed with the quality of care provided by the home. They also confirmed that they were welcomed when they visit. Good feedback was received from three GP practices about the care provided by the home to residents they visit. Meals are varied, well balanced and nutritious and residents liked them. The menu offers choices at each mealtime. There is a good range of daily activities and entertainments providing stimulation for mind and body. Residents confirmed that they were consulted for their opinions at regular meetings and that action is taken when they raise any issues. The home provides good quality accommodation within very pleasing grounds and both are well maintained.

What has improved since the last inspection?

The Manager has successfully obtained the Registered Manager`s qualification, which means she means she fully meets the qualification standards set for managers of care homes. The NVQ training programme continues and now 50% of the care staff team have achieved an NVQ2 or above. This means staff have a good grounding in the knowledge they need to provide good care. Staffing levels through the night have been increased and are to be increased again to four. The Manager has done this because the home occupies a large building with bedrooms spread throughout over both floors. The increased staffing team means that staff can work on both sides of the building throughout the night and be fully aware of the needs of residents at all times.

What the care home could do better:

Care planning needs to be more thorough to ensure that all assessed needs are identified and met. This is important to ensure that the staff team are well informed about the support a resident needs. In particular, where residents are unintentionally losing weight, more thorough measures need to be put in place to ensure that advice is sought and an effective care plan is put in place to help the resident. Residents at risk of falls should be assessed so that measures to reduce or prevent future falls can be put in place. The home`s recruitment procedures need to be improved. Staff had started work in the home before adequate written references were obtained. The home had also not checked the national list of people unsuitable to work in care homes (POVA List) and the Criminal Records Bureau before the new staff had started work. It is vital that these checks are done for the protection of residents and to comply with the law. The home was found to be safe and well maintained, other than the thermostatic devices on the baths need to be checked to make sure that the hot water is a safe temperature to prevent scalds.

CARE HOMES FOR OLDER PEOPLE Abbeyfield Residential Care Home 40 The Grove Gosforth Newcastle upon Tyne NE3 1NH Lead Inspector Janine Smith Announced 8 June 2005 09:30 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Abbeyfield Residential Care Home B53-B03 S429 Abbeyfield V221156 080605 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Abbeyfield Residential Care Home Address 40 The Grove Gosforth Newcastle upon Tyne NE3 1NH 0191 285 2211 0191 285 2211 N/A Abbeyfield Newcastle upon Tyne Society Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Kath Brown CRH 32 Category(ies) of OP Old Age (32) registration, with number of places Abbeyfield Residential Care Home B53-B03 S429 Abbeyfield V221156 080605 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: None. Date of last inspection 26.08.04 Brief Description of the Service: The Abbeyfield residential care home at 40 The Grove, Gosforth, provides care for up to thirty-two frail elderly people. Nursing care is not provided. The building is of an older style but has been adapted well. There are a variety of aids and adaptations around the building to help residents to move about more independently. Single bedrooms are provided throughout which each have an en-suite toilet. The bedrooms are located on the ground and first floor of the building which has a passenger lift. The home has several lounges and dining areas. Two assisted baths and one shower are provided, along with four separate toilets. The home is set with large, attractive grounds filled with mature plants which are well maintained. The home is run by the Abbeyfield Society. Abbeyfield Residential Care Home B53-B03 S429 Abbeyfield V221156 080605 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home were given prior notice of this inspection which took place over 8 hours. A partial tour of the premises took place and a sample of care records were inspected as well as other records. The Manager, three of the staff on duty and eleven residents and a visitor were spoken to. Prior to the inspection comment cards were made available in the home for residents and relatives to complete and forward to the Commission. Two comment cards were received from residents and three from relatives. Comment cards were also forwarded to GP practices, who have patients living in the home, and three replies were received. This was a very positive inspection and there was good evidence that the home is well run and that residents were satisfied and happy living here. What the service does well: A resident spoken to, who had recently come to stay in the home, confirmed that it had been a positive choice to move here and that they had received full information about the home and the services provided. The home has caring and enthusiastic staff who enjoy their work. Residents spoken to said that the staff are kind and helpful to them. Relatives are also very impressed with the quality of care provided by the home. They also confirmed that they were welcomed when they visit. Good feedback was received from three GP practices about the care provided by the home to residents they visit. Meals are varied, well balanced and nutritious and residents liked them. The menu offers choices at each mealtime. There is a good range of daily activities and entertainments providing stimulation for mind and body. Residents confirmed that they were consulted for their opinions at regular meetings and that action is taken when they raise any issues. The home provides good quality accommodation within very pleasing grounds and both are well maintained. Abbeyfield Residential Care Home B53-B03 S429 Abbeyfield V221156 080605 Stage 4.doc Version 1.20 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 full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Abbeyfield Residential Care Home B53-B03 S429 Abbeyfield V221156 080605 Stage 4.doc Version 1.20 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Abbeyfield Residential Care Home B53-B03 S429 Abbeyfield V221156 080605 Stage 4.doc Version 1.20 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 and 5. The process followed in the home ensures that potential residents are provided with details of the services the home provides which helps them to make an informed decision about coming to stay in the home. The home carries out a detailed assessment prior to agreeing to admit people into the home to ensure that the home can meet their needs. However, relevant information from this assessment had not being carried forward into the care plan which means care staff are not fully informed about the resident’s care needs. EVIDENCE: Inspection of the records for a recent admission showed that a full assessment had been carried out prior to their admission, including making contact with their GP to obtain information about health care needs. However, the care plan put in place was very brief and did not contain all of the relevant health care information and two of the staff did not know important information. The resident confirmed that they had visited the home and received full information about the way it was run and the costs of care before moving in Abbeyfield Residential Care Home B53-B03 S429 Abbeyfield V221156 080605 Stage 4.doc Version 1.20 Page 9 for a trial stay. The resident was also very happy with the care and attention received during their stay. Abbeyfield Residential Care Home B53-B03 S429 Abbeyfield V221156 080605 Stage 4.doc Version 1.20 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8 and 10. There are generally good arrangements in place to ensure that residents’ health care needs are met, but care planning needs to be improved to ensure that all needs are clearly addressed to ensure that the staff team are fully informed and aware of the support they need to provide. EVIDENCE: Four care plans were inspected. These were found to contain relevant individual plans of care but, in some cases, did not cover all needs particularly as individual residents became more frail and their needs more complex. Daily entries into case records were not being made and some entries available gave little indication of the care given. It is particularly important that this is done where residents need total support from the care staff. This was particularly evident for one resident who had been refusing food and fluid but there was no written care plan to address this and a lack of evidence to show how this was dealt with and how her day to day welfare progressed. This resident was being weighed monthly but there was no evidence to show that action had been taken in respect of significant weight loss. Abbeyfield Residential Care Home B53-B03 S429 Abbeyfield V221156 080605 Stage 4.doc Version 1.20 Page 11 One resident had experienced health problems, including several falls, but there was a lack of evidence to show that a falls risk assessment had been carried out and a plan put in place to prevent falls. It was also difficult to find out from the records when residents had seen opticians and dentists and the results of these consultations. There was evidence that GPs and Community Nurses were regularly consulted for advice and treatment. Comment cards received from three GP practices used by residents confirmed that the home communicated clearly and worked in partnership with them; that the staff demonstrated a clear understanding of the care needs of residents and that the practices were satisfied with the overall care provided to residents in the home. All of those residents spoken to, who could comment, said that they were treated well by the staff and well cared for. One resident who completed a comment card, wrote ‘I have not experienced many homes but I find that this is one of the best organised and with a very cheerful, helpful staff who are always ready to help with a willing smile’. A regular visitor, spoken to during the inspection, said that her relative was very well cared for and ‘loved’ by the staff. Of the three comment cards received from relatives, two additional comments were received, as follows. One stated, ‘Excellent level of care. Staff very friendly and committed. Frequency of use of agency staff means information not always passed on’. Another stated, ‘This Abbeyfield is a very friendly place. Staff are always willing to respond positively to suggestions’. It was apparent during the inspection, that attention was paid to residents’ dignity and staff were seen to act respectfully at all times. A resident said that her privacy was respected by the staff at all times. The comment cards received from three GP practices confirmed that they were able to see their patients in private when they visited the home. The medication system was not examined on this occasion. Abbeyfield Residential Care Home B53-B03 S429 Abbeyfield V221156 080605 Stage 4.doc Version 1.20 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13 and 15. Social activities and meals are both managed, creative and provide daily variation and interest for people living in the home. Visitors are made welcome which enables residents to keep in close contact with their family and friends. EVIDENCE: There is a good programme of activities in place including crafts, games, keep fit, hand massages and manicures, flower arranging, photography and outdoor walks. Regular social occasions are organised such as afternoon teas and a pre-lunch sherry. One member of staff has specific responsibility for organising activities and during discussion with her it was evident that she puts a great deal of thought in this to ensure that the activities were suitable for residents with disabilities, for example, she had considered the needs of people with visual impairment. Residents spoken to were aware of the activities, although not all wished to participate and these wishes are respected. Residents confirmed that there are regular residents’ meetings during which they are consulted for their views and opinions. Abbeyfield Residential Care Home B53-B03 S429 Abbeyfield V221156 080605 Stage 4.doc Version 1.20 Page 13 A visitor confirmed that they were welcomed and that there were no restrictions on visiting. A relative completing a comment card stated, ‘…Staff welcome visitors very positively, offering tea, coffee, etc.’. A number of people living in the home were spoken to and those who commented on the food said how good it was. Choices are provided at each meal. On the day of inspection, the lunch comprised prepared fruits or pearl barley soup, roast lamb or chicken casserole with roasted and mashed potatoes, three vegetables and Yorkshire pudding followed by ginger sponge with custard or ice cream. One resident was heard to praise the soup very highly, saying it was like that made by her mother. Parts of the meal were sampled and found to be well presented, tasty and nutritious. It was recommended that the chef be provided with further information on how to meet the needs of people who need fortified diets. Abbeyfield Residential Care Home B53-B03 S429 Abbeyfield V221156 080605 Stage 4.doc Version 1.20 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18. There is a complaints procedure, which works well as residents have confidence that they can raise any issues and know that they will be dealt with. Staff have good knowledge and understanding of Adult Protection issues which protects residents from abuse. EVIDENCE: The home has a complaints procedure, which the Manager stated was given to residents with the Service User Guide on admission. There was evidence that any complaints are listened to and investigated and a written record kept. The home had received one complaint since the last inspection. Another complaint has been made to the Commission about the quality of care given to a resident, which is currently being investigated. Residents living in the home stated that they would readily raise any issues of concern with the Manager. One also said that they were visited regularly by a member of the Abbeyfield Committee, who listened and had acted on an issue she raised. A procedure for responding to allegations of abuse has been drawn up previously. Carers spoken to during the inspection were familiar with the policy and adult protection issues. It was confirmed from a sample of training records that staff are given training in Adult Protection. However, vetting procedures need to be tightened up to ensure that satisfactory checks of the Protection of Vulnerable Adults List are carried out before staff are employed in the home. Abbeyfield Residential Care Home B53-B03 S429 Abbeyfield V221156 080605 Stage 4.doc Version 1.20 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 22, 23, 24, 26 and 26. The home was well maintained with good quality furnishings and décor, which creates a pleasant and homely environment for those living there. Steps need to be taken to ensure that the temperature of hot water delivered to baths is safe for residents. EVIDENCE: A tour of the premises was undertaken and a small number of bedrooms viewed. The home is well maintained and décor and furniture is of good quality. There are spacious lounges and dining areas. Residents’ bedrooms were personalised to their tastes. Each has an en-suite toilet. There are an adequate number of bathrooms with equipment to help those with physical disabilities and some separate toilets throughout the home. There are large, well tended gardens with pleasant sitting areas. Abbeyfield Residential Care Home B53-B03 S429 Abbeyfield V221156 080605 Stage 4.doc Version 1.20 Page 16 Hot water temperatures were tested. The temperature of water supplied to one bath was too hot, at 47o centigrade. A letter was left with the Manager advising that immediate action must be taken to put this right. The temperature in the home was pleasant. The Manager stated that all radiators, bar one are fitted with protective guards. It is intended to fit a guard to the remaining radiator, which is located in a staffing area, because some residents use this corridor as a short cut. The home was very clean. Staff spoken to during the inspection were aware of good infection control measures and said that protective clothing is provided. There are good laundry facilities in place. Abbeyfield Residential Care Home B53-B03 S429 Abbeyfield V221156 080605 Stage 4.doc Version 1.20 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 and 30. Good staffing levels are maintained which means that there are always enough staff on duty to meet the needs of residents. There are good training arrangements in place, which means staff are given a thorough grounding in the areas they need to know to provide good care. The procedures for the recruitment of staff are not robust and do not provide the safeguards to offer protection to people living in the home. EVIDENCE: Examination of staff rotas and discussion with the Manager and members of the staff team provided evidence that the numbers of staff are as follows:8 a.m. to 10 p.m. 5 10 p.m. to 8 a.m. 3 (sometimes 4) waking This is enough to meet the needs of residents. There is a senior member of staff on each shift. The Manager’s hours are not included in the above and in addition, staff are employed for duties such as food preparation, cleaning, laundry and gardening. The Manager has increased the staffing levels through the night since the last inspection to take account of the design of the building. An agency carer has been used for this purpose. She also intends to employ four night carers on a Abbeyfield Residential Care Home B53-B03 S429 Abbeyfield V221156 080605 Stage 4.doc Version 1.20 Page 18 permanent basis in the near future when suitable staff can be recruited. The home will therefore be providing more staff than the minimum required which is good practice. The home is also trying to recruit an additional chef/cook for weekends. In the meantime, an agency cook has been recruited. There is one carer below the age of twenty-one years, but she always works alongside senior staff. Staff stated that they enjoyed working in the home and were observed to be kind, caring and respectful to residents at all times. There has been some staff turnover with 7 carers and 3 ancilliary staff leaving over the past year. However, information provided by the home showed that 30 of the staff team have worked there for more than 5 years. The records of two recently employed staff were examined. Recruitment checks need to be improved. The records of one person showed that only one verbal reference had been obtained which had not been confirmed in writing, that the statutory declaration of offences was not clearly recorded and that a satisfactory Criminal Records Bureau (CRB) disclosure had not yet been obtained. In the other case, two written references had been obtained, but one of these was after employment had started and the CRB disclosure had not yet been obtained. This means that the home are not checking that the staff they employ are not on the list of people unsuitable to work with vulnerable adults (POVA List) and are therefore not complying with the law. It was confirmed from staff records and from discussion with staff that they receive induction training. Where new inexperienced staff are employed, they work as an extra member of the shift, which is good practice. 50 of the care staff team have now achieved an NVQ2 or above. Staff confirmed that they also receive advice and/or training in other areas, such as catheter care. The staff interviewed had not received awareness training or information regarding the needs of people with dementia. It is recommended that this is provided as some residents have developed dementia type conditions. Abbeyfield Residential Care Home B53-B03 S429 Abbeyfield V221156 080605 Stage 4.doc Version 1.20 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 36 and 38. The Manager provides clear leadership throughout the home, which ensures all of the staff team are aware of their roles and responsibilities. The home regularly reviews aspects of its performance through a good quality assurance system, which includes seeking the views of residents, relatives and other interested parties. There are good health and safety measures in place to ensure the safety of all who live and work in the home, but action is required in respect of hot water temperatures and fire drills. EVIDENCE: The Registered Manager, Mrs Kath Brown, has managed the home successfully for a number of years. She has recently achieved the Registered Manager’s qualification. Abbeyfield Residential Care Home B53-B03 S429 Abbeyfield V221156 080605 Stage 4.doc Version 1.20 Page 20 The positive comments of residents, relatives and the staff team give confidence that the Manager provides good leadership throughout the home and has an ‘open door’ policy which encourages good communication. The home has a quality assurance programme in place, which includes seeking the views of residents, relatives and other interested parties, to provide feedback on the quality of care provided. Discussions with the Manager and members of the staff team provided evidence that the staff are supported in their roles through regular supervision meetings. There is a system in place to ensure that the staff are given training in moving and handling skills, fire safety, first aid, infection control and good hygiene. The Fire Log Book indicated that fire safety checks are carried out routinely, however there was no evidence that fire drills were carried out at the frequency recommended by the Fire Brigade. No health and safety hazards were identified other than the temperature of hot water to a bath, mentioned earlier in this report. It was recommended that linen cupboards be kept locked as advised by the Fire Brigade. Maintenance contracts were not examined during this inspection. Abbeyfield Residential Care Home B53-B03 S429 Abbeyfield V221156 080605 Stage 4.doc Version 1.20 Page 21 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. Where there is no score against a standard it has not been looked at during this inspection. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 2 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 2 3 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 3 x x 3 x 3 Abbeyfield Residential Care Home B53-B03 S429 Abbeyfield V221156 080605 Stage 4.doc Version 1.20 Page 22 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 3 and 7 Regulation 15 Requirement The care plan must reflect all care needs identified through the assessment process. Ensure that adequate ongoing notes are kept of residents day to day progress. This should also include food and fluid intake charts where appropriate. Carry out nutritional assessments and ensure that effective care plans are put in place where residents have unplanned weight loss. Introduce a system for assessing the risks of falls and implementing a prevention plan. Ensure that the thermostatic control device on the bath is functioning correctly to deliver hot water at no more than 43o centigrade. Satisfactory checks of the POVA list must be obtained before staff are employed in the home. CRB disclosures must be obtained. Two written references must be obtained before staff are employed. The homes declaration of any criminal offences should be amended to include disclosure of any Timescale for action 31/8/05 2. 8 14(2) & 15(2) & 12(1) 14(2) & 15(2) & 13(4) 31/8/05 3. 4. 7&8 25 31/8/05 13/6/05 5. 29 19 31/8/05 Abbeyfield Residential Care Home B53-B03 S429 Abbeyfield V221156 080605 Stage 4.doc Version 1.20 Page 23 cautions. 6. 38 23(4)(e) Carry out fire drills in accordance with Fire Brigade advice. Keep linen cupboard doors locked. 31/7/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard 15 4 & 30 Good Practice Recommendations Provide information to the chef on fortifying diets. Provide awareness training for staff about meeting the needs of people with dementia type conditions. Abbeyfield Residential Care Home B53-B03 S429 Abbeyfield V221156 080605 Stage 4.doc Version 1.20 Page 24 Commission for Social Care Inspection Northumbria House Manor Walks, Cramlington Northumberland NE23 6UR 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 Abbeyfield Residential Care Home B53-B03 S429 Abbeyfield V221156 080605 Stage 4.doc Version 1.20 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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