Inspection on 16/01/07 for Abbeygate Care Centre

This inspection was carried out on 16th January 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Abbeygate Care Centre 11/07/08

Abbeygate Care Centre 14/01/08

Abbeygate Care Centre 12/06/07

Abbeygate Care Centre 16/02/06

Abbeygate Care Centre 25/10/05

Abbeygate Care Centre 17/03/05

Abbeygate Care Centre 15/02/05

Abbeygate Care Centre 12/02/04

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Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Abbeygate Care Centre 2 Leys Road Brockmoor West Midlands DY5 3UR Lead Inspector Mrs Amanda Hennessy Key Unannounced Inspection 16th January 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Abbeygate Care Centre DS0000025048.V326109.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. Abbeygate Care Centre DS0000025048.V326109.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbeygate Care Centre Address 2 Leys Road Brockmoor West Midlands DY5 3UR 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) 01384 571295 01384 571295 Mr Dasrath Sahadew Mrs Hilary May Sahadew Mr Dasrath Sahadew Care Home 17 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia - over 65 years of age (1), Old age, of places not falling within any other category (16), Physical disability over 65 years of age (1) Abbeygate Care Centre DS0000025048.V326109.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service Users to include 16 OP and up to 1 MD(E) and 1 PD(E) Date of last inspection 16th February 2006 Brief Description of the Service: Abbeygate Care Centre is a detached building, with original parts of the house dating from 1845, situated in Brockmoor, which is to the west of Brierley Hill and close to the Merry Hill Shopping Centre. Sited in its own grounds, with mature gardens and car parking available, it has been adapted and extended for use as a Care Home for older people. Accommodation comprises 17 single bedrooms (8 with en-suite), plus two communal lounges, one of which includes a conservatory/dining area. A shaft lift provides access to the first floor. The Home is registered for the provision of personal care only, with any required nursing care being provided through local health services. The home is managed by one of the joint providers with a staff team consisting of a deputy, senior carers and care staff in addition to some ancillary staff. Fees vary between £343 and £385 and are dependant on the needs of the service user and the type of room that will be occupied. Items that are not covered by the fee include hairdressing, chiropody, toiletries and newspapers. Abbeygate Care Centre DS0000025048.V326109.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection undertaken by one Inspector between 10.00 and 15.00 on the 16th January 2007. The inspection included a tour of the home, talking to service users and staff, A review of information supplied by the Manager (pre inspection questionnaire) was also undertaken and expanded upon during the visit. Care records were reviewed as part of the “case tracking” of three service users. Two of the previous five requirements were found to have been met, twentyfour new requirements were made as a result of this inspection. The Inspectors would like to thanks the homes staff and service users for their assistance and hospitality during the inspection. What the service does well: What has improved since the last inspection? What they could do better: Abbeygate Care Centre DS0000025048.V326109.R01.S.doc Version 5.2 Page 6 Staff need to ensure that new residents have a plan of care which has been developed from their care assessment when they move into the home so staff have instructions on their needs and capabilities. Improvement is required in the storage and safe keeping of medicines. The quality assurance programme needs to be introduced with areas of improvement needing to focus around meal choices and staff supervision and mandatory training. Liquid soap and adequate hot water must be available to enable staff to effectively wash their hands and minimise the risk of cross infection and residents hot water to wash and bathe in. 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 be made available in other formats on request. Abbeygate Care Centre DS0000025048.V326109.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Abbeygate Care Centre DS0000025048.V326109.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3, 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can be assured that their needs will be assessed in full prior to their admission and that the home will be able to meet their needs and they can visit the home. EVIDENCE: All service users have a comprehensive assessment of their needs before they come to live at the home, which is undertaken by the Manager /Proprietor. The manager ensures that only residents who have similar needs are admitted and tries to ensure that they will fit in well with the other residents. The Manager writes to prospective service users to confirm that following the assessment of need, the home is able to meet their needs, this letter also gives additional information such as confirmation of the room to be occupied and fees that are payable and where the service user guide and inspection report are available. A copy of the complaints procedures is also included with this letter. Abbeygate Care Centre DS0000025048.V326109.R01.S.doc Version 5.2 Page 9 Prospective residents and their families always are given the opportunity to visit the home before they make the decision to coming to live at the home which was confirmed by residents and their families. Terms and conditions of residency are now given to new service users with their letter of acceptance although there can be a delay in their return. One service user file only contained the placing contract from Dudley Social Services, so it was not clear whether all service users have had terms and conditions of residency. Abbeygate Care Centre DS0000025048.V326109.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans are available but a lack of care instructions when new residents move into the home and insufficient risk assessments may mean that residents needs are not always met. Deficits in the safe keeping and administration of medication and particularly controlled drugs may compromise residents. EVIDENCE: Residents have a plan of care, although a plan of care had not been developed for the resident who had been admitted two days previously. Care instructions should be available as a result of their assessment of need for all residents from the time their admission. Care plans are reviewed at least monthly and are developed and reviewed wherever possible with the resident. Staff ensure that residents have access to health care services with residents are seen regularly by their GP and when appropriate district nurse, chiropodist, optician and dentist. Abbeygate Care Centre DS0000025048.V326109.R01.S.doc Version 5.2 Page 11 Risk assessments are being developed as required at the previous inspection but need further development. Residents are weighed regularly and it was lovely to see that a new resident had put weight on since they had moved to the home. There was some uncertainty whether staff had acted promptly when two residents had lost weight with one resident having lost 11 pounds in eight weeks. Residents are generally weighed when they have a bath and as a result there can be a delay checking the weight of new residents. Care plans that give staff instructions how to care for diabetic residents need to be more specific as they identify that the blood sugar should be within normal limits. Care plans need to identify what are “normal” or acceptable limits readings and actions that are required when their blood sugar is outside these parameters. All staff who administer medicines have received required training but due to the concerns about medication were identified, further update training may be beneficial. Particular concern was that staff had been using unnamed eyedrops and the eye-drops that had another name on them for a newly admitted resident. There was also concern about the safe storage of controlled drugs. For further information about improvements required please refer to the requirements and recommendations section of this report. Service users said that staff protect their privacy and dignity – with a note on bed doors as a reminder to knock and wait. Abbeygate Care Centre DS0000025048.V326109.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service user’s expectations and preferences are generally met but service users are not all aware that an alternative to the main meal is available. Services users are able to exercise choice and control over their lives and maintain contact with friends and family. EVIDENCE: The home has activities and a routine that is flexible for residents and meets their needs, capabilities and preferences. Staff explores residents’ interests, with case files seen containing ‘life biographies’ giving them insight to their interests. There is a daily record of activities made available to residents. Residents said: “ There are things to do if you want to but I usually spend the afternoon in my room reading”. Visitors confirmed there was no restriction of visiting hours (as per the Home’s Policy), and they were able to enjoy sufficient privacy when visiting. There is a menu but this is limited giving just one choice of main meal for lunch. Staff confirmed that the cook knows resident’s likes and dislikes and if Abbeygate Care Centre DS0000025048.V326109.R01.S.doc Version 5.2 Page 13 the do not like the main meal of the day an alternative will be offered. The majority of residents said the food was good with the following comment typical: “ the meals are very good, but there is much to much for me.” Another resident said : “ I don’t always like the food and they never offer me any thing else”. Unfortunately as some residents have short term memory loss there is a need to ensure that residents are always aware of additional choices. Residents have a continental breakfast with cereals and toast daily. The Manager stated he had found that when residents have a large breakfast they are unable to eat their lunch and that the lack of a cooked breakfast was always made clear before residents agree to come an live at the home although no record of this was seen. One resident said that she would occasionally like a cooked breakfast qualifying this by saying: “ We didn’t even have a cooked breakfast on Christmas Day”. At teatime there is a choice of a hot snack or a selection of sandwiches with a snack and a hot drink also being available before residents go to bed. Abbeygate Care Centre DS0000025048.V326109.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has an appropriate complaints policy that is fully accessible to residents and their representatives, residents feel able to voice any concerns. The availability of an appropriate adult protection policy and staff that have had adult protection training will further safeguard residents from risk of abuse. EVIDENCE: The home has a detailed complaints procedure which is displayed in the reception area of the home, is in the service user guide and is given to every new resident alongside the letter confirming that the home is able to met their needs. The home has had no complaints since the last inspection. Service users and their families said if they had any concerns they would discuss them with the Home Manager. The homes adult protection policy was not available at the time of the visit as the manager was developing it following a recent visit undertaken by Dudley Social Services. A copy of Dudley Local Authority policy was however available and when available the homes policy should be linked to this policy as required by the “ No Secrets legislation”. Staff have not had recent training in the Protection of Vulnerable Adults, the manager confirmed that he would arrange this. Abbeygate Care Centre DS0000025048.V326109.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is pleasant, homely and well maintained it a homely and comfortable place for its service users to live. Infection control measures within the home are generally appropriate and minimise the risk of cross infection. EVIDENCE: The home is homely warm and comfortable and has character with many of the original features of the old house. Residents commented : “ Its lovely and cosy here despite the rain and cold outside.” The manager/ proprietor has a maintenance programme which ensures that the home is pleasantly decorated and furnished. Abbeygate Care Centre DS0000025048.V326109.R01.S.doc Version 5.2 Page 16 There is an assisted bathroom downstairs but there are no assisted bathing facilities upstairs with the majority of residents preferring to be bathed in downstairs bathroom. The home has appropriate procedures to minimise the risk of cross infection. Staff have appropriate protective equipment available them although no liquid soap or paper towels were available in the staff toilet and the water flow and temperature of the water here was inadequate not enabling effective hand washing. The kitchen mop was inappropriately in the laundry and there was a need to store mops inverted. There was no laundry- cleaning schedule and although the walls are part tiled there is a need that all the walls should be easily cleanable. Abbeygate Care Centre DS0000025048.V326109.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels meet service users needs. Staff are experienced and well trained although more consistent and comprehensive induction training is required. Recruitment and selection procedures are generally robust and safeguard the service users. EVIDENCE: There are two care staff on duty at all times with a cook and domestic also on duty in the mornings. Staffing levels meet the needs of residents currently accommodated. Residents were very complimentary about the homes staff one comment received was: “The staff are always very attentive.” The home has six of its twelve care staff qualified to a minimum of National Vocational level (NVQ) two in care (50 ) meeting the requirement of at least 50 of care staff with NVQ level 2 and above. Recruitment and selection of staff is generally good, meeting required standards to safeguard residents. The Manager however advised not to accept references that are : “ To whom it may concern.” One member of staff had just one reference and not the required two which was also discussed during the inspection. No staff Abbeygate Care Centre DS0000025048.V326109.R01.S.doc Version 5.2 Page 18 commence employment with out receipt of an acceptable criminal records check. All new staff receive induction training in the form of an information giving/sharing checklist. The home does have an induction that meets National Training Organisations standards, although evidence of this induction was not available in any of the staff files seen. Abbeygate Care Centre DS0000025048.V326109.R01.S.doc Version 5.2 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 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33, 35, 36, 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager has the necessary skills and experience to run the home to meet its stated purpose, aims and objectives. The development of the quality assurance system will ensure that the home is run in the best interests of the service users. Health and safety practices and training although generally acceptable needs further attention to ensure that residents health and safety is safeguarded. Abbeygate Care Centre DS0000025048.V326109.R01.S.doc Version 5.2 Page 20 EVIDENCE: The home’s manager / proprietor is Mr Dasrath Sahadew who has owned the home for ten years and managed it for five years. Mr Sahadew is a registered general and mental health nurse and has held senior nursing and general management positions. He also had also had experience managing another home. The Proprietor has recently purchased a quality programme but due to his recent illness has been unable to commence this. A stakeholder survey was undertaken in August 2006 but there remains a need to incorporate the findings of the surveys into a report that can be shared with all interested parties. The majority of services users have their finances managed by their families. The home’s staff do not manage the finances of any service users, although small amounts of money are kept for hairdressing. Secure facilities are available for the safe keeping of service users personal money and valuables if required. Written records are available for all transactions which detail the reason for the withdrawal and two signatures, although it is recommended that receipts are completed for hairdressing, as the hairdresser currently signs their personal money log which may is a potential breach of confidentiality. Some staff have received supervision but supervision was not up to date due to the managers recent illness. The Manager/ proprietor has the general responsibility for health and safety. Procedures to protect service users include regular checks on the fire alarm, and emergency lighting, hot water checks were not available at the time of the inspection. Maintenance contracts were up to date with the exception of the electrical installation test which the Manager stated will be addressed. Records identify that staff regularly attend mandatory training in fire safety and moving and handling. Plans are in place for further training that will include first aid, basis food hygiene and infection control. It was identified at the previous inspection that whilst there was not a full assessment of safe working practices there should be moving and handling risk assessments in place for any task that involved use of aids. If staff are expected to use a bath hoist to transfer residents into the bath then these instructions should be documented. Abbeygate Care Centre DS0000025048.V326109.R01.S.doc Version 5.2 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. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x 2 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 2 2 x x x x x x 2 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 2 2 x 2 Abbeygate Care Centre DS0000025048.V326109.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 Requirement The registered provider must ensure that care instructions or an interim plan of care is available when the service user moves into the home. Service users must be weighed at least monthly or more frequently as identified by their risk assessment and plan of care The registered provider must ensure that residents receive appropriate attention when their weight becomes a cause for concerns. Care plan for residents with diabetes are more detail and specify the frequency of blood glucose monitoring and the parameters of acceptable blood glucose and actions that should be undertaken when the blood glucose is outside these parameters. To update the permissions for the homes homely remedies policy with residents GPs as appropriate. Timescale for action 28/02/07 2 OP8 13(6) 28/02/07 3 OP8 12(b) 28/02/07 4 OP8 12(1)(b) 28/02/07 5 OP9 13 (2) 28/02/07 Abbeygate Care Centre DS0000025048.V326109.R01.S.doc Version 5.2 Page 23 6 OP9 13(2) The appropriate arrangements 28/02/07 must be made for the recording, handling and safe keeping of medicines for example: Staff must check the prescription again before it goes to the pharmacy. The receipt of all medicines must be recorded Staff must sign for the administration of creams and lotions. Medication stick on labels must not be used onto the medication record chart when additional medicines are received. Two members of staff must sign to confirm that the hand written record of medication required is correct. Temazepam must be stored separately from other medicines as required as a schedule 3 controlled. The home must have a controlled drugs register to enable appropriate and required records to be maintained of controlled drugs that are received, stored and administered at the home. Medicines must be stored securely including those medicines that are stored in the homes refrigerator. Residents must be aware of additional food choices that are available to them should they no require the food choice available. Inventories of resident’s property are to be consistently maintained. The requirement should have been addressed by 15/03/06 The home must have a DS0000025048.V326109.R01.S.doc 7 OP9 13(2) 31/01/07 8 OP9 13(2) 31/01/07 9 OP9 13(2) 31/01/07 10 OP15 16(2)(i) 28/02/07 11 OP18 13 (6) 15/02/07 12 OP18 13(6) 28/02/07 Page 24 Abbeygate Care Centre Version 5.2 13 14 OP18 OP19 13(6) 16,23 protection of adults policy available that links to Dudley protection of vulnerable adults policy. Staff must have training in the Protection of Vulnerable Adults. The maintenance programme addresses: The water marks following the leak to the lounge ceiling. The cracked panes of glass in the French door of the downstairs bedroom. The hole in the carpet at the top of the main staircase. Staff must be able to effective wash their hands and liquid soap and papers towels must be available throughout the home where staff need to wash their hands. Mops must be stored inverted and only used within designated areas. The laundry walls and floor must impermeable and easily cleanable. All staff must have two written references. All staff must receive comprehensive induction training that is recorded and that meets National Training Organisation standards. A report must be made available that summarises the findings of the service user survey and which can be shared with all interested parties Inventories of resident’s property are to be consistently maintained. This requirement should have been addressed by the 15/03/06 Staff must receive regular and required supervision that is DS0000025048.V326109.R01.S.doc 31/03/07 31/03/07 15 OP26 13(3) 31/01/07 16 17 18 19 OP26 OP26 OP29 OP30 13(3) 13(3) 19 18 31/01/07 28/02/07 31/01/07 28/02/07 20 OP33 35 31/03/07 21 OP35 13 (6) 15/02/07 22 OP36 18 28/02/07 Page 25 Abbeygate Care Centre Version 5.2 23 OP38 13 (5) 24 OP25 OP38 23(2)(p) 25 OP38 16 26 27 OP38 OP38 23(4) 18 recorded. There should be clear written directions in place (in the form of a moving and handling risk assessment) for any resident that requires the use of aids (i.e. bath hoists). Further advice to be sought from Environmental services. This requirement should have been addressed by the 31/03/06 Hot water checks including the flow and return hot water temperature must be regularly undertaken with a record of the findings. A copy of the electrical installation test certificate must be available with a copy forwarded to the Commission for Social care Inspection. All staff must receive two fire drills annually The registered proprietor must have a training plan that ensures that all staff receive required statutory training, development and induction training. 31/03/07 17/02/07 17/02/07 31/03/07 31/03/07 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 5 Refer to Standard OP8 OP9 OP9 OP9 OP9 Good Practice Recommendations Residents are weighed within 48 hours of their admission The home has a separate medication fridge. Staff undertake refresher training in the safe handling of medicines. The temperature is taken and recorded of the room where medication is stored. The number of tablets left each month and then carried DS0000025048.V326109.R01.S.doc Version 5.2 Page 26 Abbeygate Care Centre 6 7 8 9 10 11 12 13 OP10 OP15 OP18 OP26 OP29 OP30 OP35 OP36 forward for use in the following month is recorded. The manager should monitor resident’s views in respect of intimate personal care. A review of residents choices regarding food and provision of breakfast is undertaken. The behaviour of the one resident (as discussed at the time of the report) should be monitored. A laundry cleaning schedule is available. References are not accepted when they are addressed to “ to whom they may concern” and there is no evidence that they have been solicited by the home. The staff training matrix contains dates that staff attend training to enable dates for a review of training to be easily identified. Receipts are available of money paid by residents for hairdressing A matrix is available of all dates that staff receive supervision. Abbeygate Care Centre DS0000025048.V326109.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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. Extracts may not be used or reproduced without the express permission of CSCI Abbeygate Care Centre DS0000025048.V326109.R01.S.doc Version 5.2 Page 28 - 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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