Inspection on 08/08/06 for Abbeygate

This inspection was carried out on 8th August 2006.

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.

Other inspections for this house

Abbeygate 06/10/05

Abbeygate 11/08/04

Abbeygate 19/04/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Abbeygate 71 Beach Road Weston Super Mare North Somerset BS23 4BG Lead Inspector Pippa Greed Key Unannounced Inspection 09:25 8th August 2006 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 Abbey Gate DS0000008027.V302459.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. Abbey Gate DS0000008027.V302459.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbeygate Address 71 Beach Road Weston Super Mare North Somerset BS23 4BG 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) 01934 621166 01934 419244 general-manager@abbeycarehomes.org.uk WSM Free Church Housing Association Mrs Joan Patricia Duffy Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21) of places Abbey Gate DS0000008027.V302459.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th October 2005 Brief Description of the Service: Abbeygate is owned by Weston-super-Mare Free Church Housing Association. The home overlooks the sea front at Weston-super-Mare and is able to accommodate 21 elderly residents, who require personal care only. The property is a large Victorian house with a long conservatory leading to an annex at the rear. There is a large lounge, leading to a well-stocked library. This is used for daily prayers and Sunday church services. A television lounge and dining room are also located on the ground floor. There is a wellmaintained garden to the front and a sheltered courtyard outside the conservatory. A local park is situated behind the home. Buses pass the home; otherwise a car would be necessary to access the town centre. Abbey Gate DS0000008027.V302459.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over the course of one day (7.5hrs) on 8th August 2006. It was conducted by Regulation Inspector Pippa Greed. The inspector spoke to six service users, four staff, and one house visitor (volunteer) visiting the home. The inspector was also assisted by the manager, Mrs Joan Duffy throughout the inspection process Three service users files were selected for case tracking. As part of the inspection process the inspector used ‘case tracking’ as a means of assessing some of the national minimum standards. This process allowed the inspector to focus on a small group of people living in the home. All records relating to these people were inspected, along with the rooms they occupied in the home. Three staff files were checked and documents related to the running of the home were examined. A tour of the building took place and the communal areas and some service users’ rooms were viewed. Mrs Joan Duffy is the registered manager and she is supported by two deputy managers. The home uses relief deputy managers to cover maternity leave or absences. Surveys were sent out to service users, relatives and medical and health care professionals. Six surveys were received from service users. Two comment cards were received from relatives. All comments received from relatives were overall positive stating that they were made welcome and kept informed. A relative commented ‘We are more than satisfied with the love and care provided by everyone at Abbeygate’. Both relatives stated that they have not felt the need to make a complaint, and one stated they were not aware of the homes’ complaint procedure or how to access a copy of the Inspection report. One comment card was received from a doctor who stated that they felt satisfied with the overall care provided by the home. All the comments received from service users on the day of the inspection and through anonymous surveys were complimentary about the home and included comments such as ‘They are extremely attentive’, ‘All staff members are friendly, cheerful, helpful and communicative’, ‘I am very happy to be here’ and ‘I highly recommend the home to anyone’. The inspectors would like to thank the service users, staff and the manager for their support and assistance with the inspection process. The current fee level is £336 per week. Abbey Gate DS0000008027.V302459.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Five requirements have been made at this inspection. Care plans viewed by the inspector were not fully reflective of the needs of service users. Although positive steps have been taken to improve the care plans, the care plans will need more details. Whilst the home has an Abuse, Whistle blowing policy and Complaints procedure, it would need to include the contact details of the Commission for Abbey Gate DS0000008027.V302459.R01.S.doc Version 5.2 Page 7 Social Care Inspection and Local Social Services. This is evident in the Service User’s guide but not provided within the home policy and procedures. Whilst the home safely stores hazardous chemicals securely, it would need to implement a Control of Substances Hazardous to Health (COSHH) file to evidence assessment and information relating to chemicals used in the home and how risk has been minimised. Hoists used in the home require regular maintenance checks every six months. It was brought to the manager’s attention that the hot water outlet for the two assisted bathrooms exceeded the Health and Safety Executive (HSE) recommended limit. The manager will take proactive steps to address this. 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. Abbey Gate DS0000008027.V302459.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 Abbey Gate DS0000008027.V302459.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5, Standard 6 is not applicable to this service The quality in this outcome group is good. The home provides a statement of purpose, and welcome pack that clearly sets out the objectives and philosophy of the service. Prospective service users are given the opportunity to spend time in the home prior to admission. Each service user is provided with a clear statement of terms and conditions that sets out the terms and conditions of residency. EVIDENCE: Each service user is provided with a written statement of terms and condition of residency. There is a trial period of four weeks to allow prospective service user the opportunity to find out if the home meets their needs. The service user is also provided with a copy of the homes’ Statement of Purpose and a Service User’s Guide, which is kept in individual bedrooms. The Statement of Purpose has been recently updated and is reviewed annually. Abbey Gate DS0000008027.V302459.R01.S.doc Version 5.2 Page 10 Several service users had visited the home prior to moving in and a few service users were former visitors to the home, either in a pastoral role or to visit friends. All felt that they received sufficient information to enable them to make an informed choice to live here. Potential new service users are also encouraged to spend a day at the home before a final decision is made to offer a placement. Out of six service users surveys, all six confirmed that they chose to live at Abbeygate and were provided information about the home. A ‘Getting to know you’ questionnaire were viewed in the service users’ care plan, which demonstrated how the staff and service user build up a framework for care planning. However, no formal pre admission assessments were seen in the care plans. Abbey Gate DS0000008027.V302459.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, 11 The quality in this outcome group is adequate. Care plan sampled evidenced good medical and personal care provided by the home. Hand transcribed entries were not always supported by two staff signatures. Some care plans did not include service users’ social history. Not all care plans included information about the service users’ dying wishes. EVIDENCE: The inspector sampled three service users care plan. These evidenced good standard of health care provided for the service users. The care plan had a comprehensive NHS monthly checklist, which provides prompts on key areas of health care needs such as mobility needs, falls risks, appetite and fluid intake, onset of diabetes, illnesses, wound care, sleep pattern and so on. Abbey Gate DS0000008027.V302459.R01.S.doc Version 5.2 Page 12 Further details of health care provided were seen in a separate file called the residents file (not care plan). These included GP, chiropody, district nurse, optician, wellbeing clinic and diabetic nurse. It is recommended that the health care details relating to health care professionals are stored in the service users care plan. Each service user completes a ‘Getting to know you’ questionnaire providing information on preferences, such as favourite suppertime drinks and their preferred routines. This method helps the manager, staff and service user set up a framework for care planning. These are signed by the service users and reviewed by staff on a monthly basis. Personal risk assessments were seen in the care plan and these were up to date. Pre-admission assessments are stored in a separate file. However, in future the manager plans to store future assessments within the care plan. The care plan would also benefit from further details to include the service users’ social history, and wishes regarding death and dying choices. It was evident that the manager had detailed service users’ social stories (with their express consent) in the homes’ monthly newsletter. All the service users spoken to were clear that staff treated them with respect and the day-to-day routines in the home respected their dignity. This was confirmed by all of the service users surveys returned which stated that they received the care and support from staff that they needed. The inspectors observed staff interacting with service users in a friendly, professional and respectful manner. The medication file contained a list of signatures of all the staff trained to administer medications. Medication update training has been arranged for two staff to attend on 22nd and 23rd August. In relation to storage of medication and administration, appropriate levels of medication stock was stored. Photographs of service users were seen on an archived Medication Administration Record wallet but not displayed within the current medication file. Controlled drugs and returned medication were found in good order. However, hand transcribed entries on Medication Administration Record were not supported by two staff signatures. Whilst the staff check service users’ hearing aid and maintain battery care, there is no evidence to support this. The home would benefit from implementing a record in the service users’ care plan to monitor hearing aid and battery care. Abbey Gate DS0000008027.V302459.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 The quality in this outcome group is good. The routines of the home are planned around the service users’ needs and wishes. Service users are encouraged to personalise their rooms. Appropriate activities are available throughout the home. The service users are satisfied with the meals served the home. EVIDENCE: The routines of the home were seen to be flexible to meet individuals’ choices and preferences as far as possible. Service users choose to access activities provided by the home or engage in their own hobbies and pastimes. Service users are actively encouraged to keep in contact with family and friends living in the community. Visitors are made welcome at any time. Service users can choose to entertain visitors in their room, any one of the communal areas or in the patio garden. The social events diary kept by the home record the date and the activity but not who attended. This was mentioned in the last inspection report. The home Abbey Gate DS0000008027.V302459.R01.S.doc Version 5.2 Page 14 would benefit from recording in individual care plans, service users who attended the activities. Examples of recent events are: - flower arranging, nail and beauty, bingo, keep fit, afternoon teas & entertainment, and indoor bowls tournament. The service users at Abbeygate have also enjoyed trips recently to the Bishops Palace in Wells with lunch, and Gough House fete. The inspector received positive feedback through surveys and discussion with service users. All commented highly on the care provided at Abbeygate. The comments included ‘I am very happy to be here’ and ‘The setting is excellent’. The inspector spoke with a house visitor (volunteer) who regularly visits the home with her dog. Service users who look forward to these visits and chats also have a supply of dog biscuits to offer the dog. This contributes to the happy environment in the home. The home issue a monthly newsletter with snippets relating to service users birthdays, service user’s background history, and up coming events planned for that month. Regular services and Holy Communion are also provided in the home. Lunchtime routine was observed during the inspection. The dining area is situated in a bright and spacious room overlooking the sea front and garden. Tables were attractively presented with napkins, vase of flowers, and condiments. Service users were seen and heard to be enjoying the meals and staff served dishes in friendly manner. There were good-natured banter and interaction between staff and service users. The food served was fresh, of good quality and homemade. Mealtime was seen to be unhurried, and support was available for service users requiring assistance. Abbey Gate DS0000008027.V302459.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17, 18 The quality in this outcome group is good. Service users were confident that they could raise complaints or concerns with senior staff. Systems are in place to ensure that service users’ rights are respected. The home has policies and procedures in place to ensure the protection of service users living at Abbeygate. The homes’ complaints procedure did not fully meet the national minimum standards and regulations. EVIDENCE: None of the service users spoken to had any complaints about the home and all were clear that should they have any complaints or concerns they would speak to the manager or another senior member of staff and that they would sort any problems. Staff spoken to were clear that they would pass on any concerns or complaints to the manager or deputy. The service users also have the opportunity to discuss things with the House visitor (volunteer) at the home who can act as an intermediary. Staff and service users confirmed that they would not hesitate to approach a senior member of staff or the manager should they have any concern. Abbey Gate DS0000008027.V302459.R01.S.doc Version 5.2 Page 16 All service users are registered to vote and their legal rights protected by the homes values, policies and procedures. Information about public services and volunteering is also included in the Statement of Purpose. Appropriate recruitment checks are undertaken for newly recruited staff. The Abuse and Whistle blowing policy were seen and did not include the Commission of Social Care Inspection and local Social Services contact details. The home has not received any complaints since the last inspection. The home does not have a complaint log. It is recommended that the home sets up a ‘Concerns, Complaint and Compliment’ file. This would need to evidence any action taken by the registered person in respect of any such complaint. Abbey Gate DS0000008027.V302459.R01.S.doc Version 5.2 Page 17 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, 22, 23, 24, 25, 26 The quality in this outcome group is good. The home has a homely environment, which provides aids and equipment to meet the care needs of the service users. The additional communal space provides service users choice and scope to meet relatives and friends in privacy and comfort. The home was clean and hygienic on the day of inspection. EVIDENCE: The home was very clean, tidy and odour free on the day of the inspection. A tour of the premises was undertaken and the inspector viewed all the communal areas and some of the service users’ private bedrooms. All service users’ rooms viewed had been personalised to reflect individuals’ choices and preferences. Service users are able to bring in personal items including small items of furniture within the space constraints of their room and in agreement with the manager. Abbey Gate DS0000008027.V302459.R01.S.doc Version 5.2 Page 18 The home is arranged over two floors with access via a chair lift or stairs. The home has two separate stairwells accessing the different sides of the home. It is a well presented home with good quality furniture and furnishings. The facilities include a separate dining room, two lounge areas and gardens. One of the larger lounge areas lies at the front of the property. This lounge has a wall divide providing a small quiet library/reading area. The other lounge area overlooks the inner courtyard. The home provides seating in a conservatory area, which again overlooks two inner courtyard gardens. There are sufficient and suitable toilet and bathing facilities available throughout the home. There are three bathrooms and one shower room in the home. The bath chair hoists were seen. However, hoist checks will require updating. Some of the bathrooms had paper towels for hand washing, liquid soap and alcohol gel provided. The ground floor shower room radiator is not covered. This may pose a burn risk as it is sited next to the toilet. It is recommended that the manager consider implementing an environmental risk assessment or install a guard. Some rooms have en suite facilities and all have wash hand basins. The home has recently completed an upgrade for some service users’ en-suite. Service users’ bedroom windows were not restricted. It is recommended that the manager implement an environmental risk assessment to minimise risks of falls (first floor) and intruders (ground level). The issue of security was discussed with the manager as the rear gate was open on the day of the inspection and the door leading to the patio was left unlocked. The inspector was informed that it is normal practice that service users are to be supervised by staff when using the patio area. Call bells are easily accessible and these are responded to promptly. Good laundry facilities are provided and service users spoken to confirmed their clothes were always well laundered and returned to them promptly in good condition. The home also provides a separate laundry area to enables the service users to do their own personal laundry. This room also has an iron and ironing board. The kitchen area was inspected and found to be clean and hygienic. The kitchen contains two side rooms containing larder, chest freezer, fridge and upright freezer. Food stored were correctly labelled and fridge/ freezer temperatures were within the correct range. Records were maintained for cooked meat temperatures. Meals were observed to be freshly prepared on the day. Cleaning schedules were displayed on the wall. Abbey Gate DS0000008027.V302459.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 The quality of this outcome group is good. Staffing levels are good and the staff were qualified to provide a high level of care. Service users have confidence in the staff that care for them. All staff are clear regarding their role in what is expected of them. EVIDENCE: On the morning of the inspection, there were three staff, one cook and one manager. During the afternoon, there were two staff and one deputy. Two staff were rostered for night duty. There are currently twenty care staff, ten of which are qualified to NVQ 2 and above therefore the staff team have the skills and experience to provide a high standard of care. Three staff files were checked. These files contained two written references and evidence of proof of identity. The files were generally well kept. The home provided information on the pre inspection questionnaire about the training that staff had been doing recently and this included mandatory training, abuse, dementia awareness, infection control, falls and stroke awareness. Staff spoken to confirmed that they were supported and Abbey Gate DS0000008027.V302459.R01.S.doc Version 5.2 Page 20 encouraged by Mrs Duffy to attend training to obtain skills and qualifications relevant to their role. One staff spoken to informed the inspector that she was placed on National Vocational Qualification (NVQ) training when she started the job and has recently obtained NVQ 2 in care. Staff spoken with confirmed that the manager operated an ‘open door’ policy that is they felt able to approach her with any queries. Staff stated that they have received induction, appraisals and some formal one to one supervision. It is recommended that formal 1:1 supervision are provided at least six times a year as outlined in the National Minimum Standards. Service users spoken to were very complimentary about staff and they were described as ‘very friendly here’. Abbey Gate DS0000008027.V302459.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36, 37, 38 The quality in this outcome group is good. The manager has the required qualifications, skills and experience and is competent to run the home. Service users and staff are kept informed and involved in the running of the home. Service users are able to take responsibility for their own finances but if they are not able to do so robust systems are in place to safeguard their financial interests. The home has clear health and safety policies and regular checks take place to ensure that the home is a safe environment. Some areas of health and safety will require improvement. Abbey Gate DS0000008027.V302459.R01.S.doc Version 5.2 Page 22 EVIDENCE: The registered manager is Mrs Joan Duffy and two deputy managers and relief deputy managers also support her. She is an experienced manager who has completed the Registered Manager Award and also an update in management skills. Service users spoken with confirmed that they felt able to approach the manager and deputies if they wanted to raise issues. The house visitor also supports the service users as an intermediary. The manager informed the inspector that the home currently does not directly handle the service users financial affair. Ten service users take responsibility for their own personal finances with relatives support. Fifteen service users have power of attorney in place. Records are kept for the management of personal allowances. Staff spoken with confirmed that they felt well supported and able approach the manager and deputies should they wished to discuss day to day running of the home. Staff also confirmed that staff meeting take place and that formal supervision are provided. It is recommended that the home provide all staff with formal supervision at least six times a year as outlined in the National Minimum Standards. A tour of the premises was made and areas seen were free from hazards and it was noted that recommendations made in the last report that replacement of light pull cord and general décor in communal bathing areas have been carried out. Records were seen that showed the following; fire equipment, stair lift, call bell and electrical equipment were subject to regular checks and had been serviced. The home contracts an external agency to test and check the water system as preventative strategy against Legionella. However, hot water outlets on communal baths were checked and found to exceed the recommended Health and Safety Executive (HSE) limit. The home manager was informed and action will be taken to address this. The accident book was checked and there were six entries made for June and July. These related to slips and falls and appropriate action were made and care plan updated. Whilst the home securely locks hazardous substances, the manager will need to set up a Control of Substances Hazardous to Health (COSHH) file to show information relating to chemicals used in the home. This would provide helpful guidance for staff on how to deal with accidental skin contact or chemical spillage. Abbey Gate DS0000008027.V302459.R01.S.doc Version 5.2 Page 23 The manager informed the inspector that new chair hoists were installed recently (under a year old). The manager was made aware that hoist would require six monthly checks and needs to be recorded. Pre inspection questionnaire sent to the Commission stated that hoist checks were last completed on 31st March 2005. Abbey Gate DS0000008027.V302459.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 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 2 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 3 18 2 2 3 3 3 3 3 3 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 2 2 2 Abbey Gate DS0000008027.V302459.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. 1. Standard OP38 Regulation 13 (4) (a) (c) 13 (4) (c) Requirement The manager must ensure that identified hot water outlet temperatures do not exceed HSE recommended limit. The manager should conduct environmental risk assessment for window restrictors, ground floor shower room uncovered radiator, rear gate being left unlocked and its impact on security. The manager must ensure that hoist checks are carried out and maintained 6 monthly. The manager must ensure that care plans are fully reflective of service users needs and wishes. This is to include details on pre admission assessment, social history, medical records and wishes linked to death & dying. The manager must ensure that the home has a COSHH file to provide staff guidance on how to deal with accidental skin contact or chemical spillage. Timescale for action 10/08/06 2. OP38 30/09/06 3. 4. OP38 OP7 13 (5) 15 30/09/06 31/10/06 5. OP38 13 (3) 31/10/06 Abbey Gate DS0000008027.V302459.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard OP9 OP16 OP36 OP7 Good Practice Recommendations It is recommended that two staff signatures support all hand transcribed entries for medication. Also, photograph ID of service users placed within the MAR file. It is recommended that the manager consider implementing a ‘Concerns, Complaints & Compliment’ file. It is recommended that formal 1:1 staff supervision are provided at least six times a year as outlined in National Minimum Standards. It is recommended that the manager consider implementing a recording tool in service users’ care plan (for those who use hearing aids) to evidence hearing aid and battery care. The manager must ensure the Abuse and Whistleblowing policy make clear that informants are able to contact Local Authority Social Services and Commission for Social Care Inspection. It is recommended that the manager consider recording in each service users’ care plan, individual and group activities attended by each service user. 5. OP18 6. OP12 Abbey Gate DS0000008027.V302459.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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