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Inspection on 04/01/06 for Abbeymere Care Centre

Also see our care home review for Abbeymere Care Centre for more information

This inspection was carried out on 4th January 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

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

What the care home does well

The home is well placed in terms of access to local facilities and to the wider area through transport links. There were some positive comments from the residents as to the food provided and the choice available, this at any time. There was also comment by residents as to the home suiting their needs and having the space to make their own choices as to how to live their lives. Feedback also indicated that visitors were welcomed to the home and that there was access to privacy for residents and their relatives to talk. The number of staff that have achieved their NVQ level 2 in care qualification now exceeds the required ratio of 50%.

What has improved since the last inspection?

There was evidence to suggest that the new owner had made a concerted effort to begin addressing matters arising from the last inspection with improvement seen in a number of areas, this despite the change of ownership only taking place late last year. It was also evident that the residents spoken to were aware of the new owner and had positive initial impressions. There was improvement in documented care plans in some case files and tissue viability and continence assessments have been developed. Residents spoken to were now aware of the homes complaints procedure. In respect of the premises the home was found to be a lot cleaner than at the time of the previous inspection and an interim decorative programme has been drawn up and commenced. This has included the fitting of radiator covers, with most now having been fitted. Recruitment checks for new staff were found to be more robust and supervision of all staff on a one to one basis has commenced.

What the care home could do better:

Despite improvements there are still many areas where work is required this including on going improvement to care plans and documentation within resident`s case files, especially in respect of risk assessments. There were numerous concerns in respect of the homes systems for administration, recording, ordering and safekeeping of medication this an area that needs auditing by the new owner. Work on improving activities available to the residents is to be continued as is recording of the same. There were some specific issues in respect of the premises that need to be addressed, this including one identified tripping hazard, some inconsistencies in the heating throughout the home and an area of rust on one bath. The owner has acceptable plans for the implementation of a quality assurance system that need to be progressed. The homes policies and procedures also need review in light of the change of ownership. The last environmental health officer`s report also identified that risk assessment in respect of safe working practice also needs improvement. It was unfortunate that some documentation that was to have been forwarded to the inspector as agreed at the time of the inspection in respect of medication audits and staff training had not been received prior to the writing of this report.

CARE HOMES FOR OLDER PEOPLE Abbeymere Care Centre 12 Eggington Road Stourbridge West Midlands DY8 2QJ Lead Inspector Mr Jon Potts Announced Inspection 4th January 2006 9:35am 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 Abbeymere Care Centre DS0000024951.V279024.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Abbeymere Care Centre DS0000024951.V279024.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Abbeymere Care Centre Address 12 Eggington Road Stourbridge West Midlands DY8 2QJ 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 395195 01384 395195 Karelink Limited Mrs Judith Christine Boden Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (12), Physical disability over 65 years of age (6) of places Abbeymere Care Centre DS0000024951.V279024.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22/9/05 Brief Description of the Service: Abbeymere Care Centre is registered for the care of 12 older people and 6 people with physical disabilities over the age of 65. The Home aims to offer residents the opportunity to enhance their quality of life by providing a safe, manageable and comfortable environment, which also includes support and stimulation to help them maximise their potential physical, social and emotional abilities. Abbeymere is a converted residential property and is located in Wollaston, within a short walking distance of the village, which has a large variety of amenities and facilities. The house is on a main bus route giving access to neighbouring towns. The building comprises of a large communal lounge, dining room and a number of bedrooms (as well as kitchen, laundry, bathroom and toilets) on the ground floor and bedrooms, bathrooms and toilets on the first floor. The home has a shaft lift and other aids and adaptations consistent with the needs of older people. There is some car parking space to the rear of the building. A company that has recently changed hands runs the home. The staffing in the home consists of a manager who supports senior and care staff as well as some ancillary staff. A director of the company provides line management support to the manager. Abbeymere Care Centre DS0000024951.V279024.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out over one day between 9.35am and 4.50pm. Methods used to gain evidence including case tracking three residents’ care, discussion with the provider, manager and some staff, sampling of numerous records including those relating to the residents, staff and premises. Information supplied by the home in the form of a pre inspection questionnaire and service user / relative comment cards were also used. Resident’s views were also obtained through discussion with some of them at the time of the inspection. Comments from residents also indicated that the staff were good at assisting residents access to community health services. Residents and staff are to be thanked for their assistance with the inspection. What the service does well: What has improved since the last inspection? There was evidence to suggest that the new owner had made a concerted effort to begin addressing matters arising from the last inspection with improvement seen in a number of areas, this despite the change of ownership only taking place late last year. It was also evident that the residents spoken to were aware of the new owner and had positive initial impressions. There was improvement in documented care plans in some case files and tissue viability and continence assessments have been developed. Residents spoken to were now aware of the homes complaints procedure. In respect of the premises the home was found to be a lot cleaner than at the time of the previous inspection and an interim decorative programme has been drawn up and commenced. This has included the fitting of radiator covers, with most now having been fitted. Recruitment checks for new staff were found to be more robust and supervision of all staff on a one to one basis has commenced. Abbeymere Care Centre DS0000024951.V279024.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Abbeymere Care Centre DS0000024951.V279024.R01.S.doc Version 5.1 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 Abbeymere Care Centre DS0000024951.V279024.R01.S.doc Version 5.1 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 the following standard(s): 1,2,3 There is information available to prospective residents that would assist with their making an informed choice. Some review of this information is required. Each resident has a written contract with the home, this in need of review in respect of some conditions judged to be unfair. Residents do not move into the home without having their needs assessed and been assured that these will be met. EVIDENCE: The provider since taking over the running of the home very recently has produced a new statement of purpose that contains in some detail the aims of the service and the arrangements for provision of the same. When read with the homes brochure, there are however some gaps in this information when compared with that detailed in the Care Home Regulations. These gaps in summary are: - A clear statement as to the age range and sex of residents that will be accommodated at the home. Abbeymere Care Centre DS0000024951.V279024.R01.S.doc Version 5.1 Page 9 - The homes fire procedures and any associated emergency procedures. - More detail as to how the home will provide for religious services of the residents choice (if any). - The number and size of rooms within the home. - A statement as to the homes procedures on emergency admission. Residents were seen to be given copies of the homes statement of terms and conditions; these signed by either the resident or their representative. There was however some concern as to some of the terms such as the expectation that a £30 deposit would be required from any resident that wanted a key to their bedroom. The new provider has not had time to review this document prior to the inspection and was clear that such terms would not be applied. It was also noted that in some cases information as to who pays the fees was not completed and the information as to the rights of the resident if there was a breach of the contract were limited. Examination of the case file for the most recently admitted resident carried evidence of the home obtaining a copy of a social work assessment, this containing sufficient information from which to draw an interim care plan. There was also evidence of the provider having confirmed the homes ability to meet the residents needs based on the information within the assessments. Other case files seen contained evidence of on going reviews of care involving funding bodies where applicable. Abbeymere Care Centre DS0000024951.V279024.R01.S.doc Version 5.1 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 the following standard(s): 7,8,9 The way the home sets out the resident’s health, personal and social care needs is improving. Residents are confident that they are assisted to access health care services as and when needed. The residents are not protected by all the homes current policies and practices relating to the handling, administration and safekeeping of medication. EVIDENCE: At the time of the last inspection the home had no bespoke care plans in place. This situation was seen to have improved with care plans now completed for a number of residents, with work on going to draw them up for others. It was agreed with the provider and manager that work to develop all care plans so that they identify clear action to ensure that all aspects of the resident’s health, personal and social care needs are met, will continue. These (plans) must be drawn up with the resident or their representative who must sign to acknowledge their agreement. Abbeymere Care Centre DS0000024951.V279024.R01.S.doc Version 5.1 Page 11 Risk assessments in respect of any hazards related to individual residents must be improved, or in cases put in place to cover any significant risks identified this to include such as: - Moving and handling (these not present in all case files) - Use of cot sides (risk assessments in place but in need of improvement) - Residents that may choose not to be checked by night staff. - Falls - Any behaviours presented by residents that may impact upon others. Discussion with residents indicated that the staff were quick to access community health services as and when needed, whether on a routine or emergency basis. This was further confirmed by documentation of residents contact with these services. There were a number of areas of concern identified in respect of the homes systems for the handing of medication these including the following: - There were some gaps in the medical administration records where medication had not been signed out, as must be the case. - There was some prescribed medication for one resident found to be unavailable as there was no stock left. This matter was addressed on the day of the inspection. - Examination of the medical cabinet revealed that there was a loose table outside of any labelled container, and one of the shelves was found to be very sticky. - Some medication was detailed ‘as directed’ with no evidence in the form of a signed prescription or confirmation from the pharmacist to evidence the regime for administration. - The homes procedure for ordering of medication needs to be revised so that the process is clearer with timescales better laid out for order, receipt etc. - There was a labelled bottle of Gaviscon found in storage with no evidence on the Medical Administration Records that it was to be taken. Observation of the administration of medication on the day of the inspection did not highlight any concerns, with this task carried out appropriately. The home was stated to have had an audit from the contracted pharmacist in the last couple of months, a copy of the report from this not available. The manager stated that she would supply a copy to the CSCI, this not received at the time this report was written. Abbeymere Care Centre DS0000024951.V279024.R01.S.doc Version 5.1 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 the following standard(s): 12,13,14 Residents find that the lifestyle within the home meets with their individual expectations, and that they do have some control and choice over their lives. Residents are able to maintain contact with family, friends and representatives as they wish. EVIDENCE: Those residents spoken to were clear that they felt that they had sufficient control and choice over their lives in the home and that the staff did encourage them to retain their independence as far as this was possible. These residents also stated that they were able to follow their chosen routines. The home does however need to improve risk assessments in respect of activities the residents are involved with that may put them at risk due to their choices, i.e. when a resident stipulates that staff do not check her at night there would need to be clear assessment of how any risks would be reduced. One resident did state that they did not vote during the last election, and would like to have the opportunity. Discussion with the manager indicated that all other residents are registered for postal votes. Records of group activities available to residents within the home were seen to be documented although these need to be kept under review in consultation with service users. Resident’s interests must be better recorded and where Abbeymere Care Centre DS0000024951.V279024.R01.S.doc Version 5.1 Page 13 possible residents must be supported and encouraged to pursue stimulation in and outside the home, which suits their needs, preferences and cultural interests. The recording of individual activities residents are currently involved with also needs better recording. Contact with friends and relatives is enabled, this confirmed by the residents spoken to who stated that there were no restrictions on visiting times. The three relatives that responded to the CSCI questionnaire all stated that they were able to see their relative in private. Information as to the homes policy on visiting was seen to be detailed in the homes statement of purpose. Abbeymere Care Centre DS0000024951.V279024.R01.S.doc Version 5.1 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 the following standard(s): These outcomes were not fully assessed at the time of this inspection. EVIDENCE: The above outcomes were not fully assessed, although the reader should note that an altercation between two residents on the 7/12/05 was not reported to the CSCI, as should have been the case. The manager must ensure that any incidents arising from altercations between residents are reported to the CSCI without delay. There was no evidence of any further incidents between these residents after, or before this date. Abbeymere Care Centre DS0000024951.V279024.R01.S.doc Version 5.1 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 the following standard(s): 19,26 Residents live in a safer and better maintained environment than at the time of the last inspection. The majority of the home was found to be clean, pleasant and hygienic. EVIDENCE: Abbeymere is an extended and adapted building set in a pleasant residential area with easy access to a nearby shopping centre and bus routes. Stourbridge town centre is a short drive away. The new provider has drawn up an interim decorative and refurbishment programme identifying areas within the home that require decorative work. Work on this programme has commenced, with repaint of some areas already undertaken. There were some specific areas that required attention these as detailed below: - A carpet tile presented a tripping hazard by the lift on the ground floor. This needs to be made safe. Abbeymere Care Centre DS0000024951.V279024.R01.S.doc Version 5.1 Page 16 - There were some inconsistencies in the heating i.e. one bedroom was cold when the heating was adjusted to compensate for excessive heat in other areas. There was supplementary heating provided in the one bedroom in question however. - There was a slight urine related odour in room 1. - There was an area of rust on the bath in the upstairs assisted bathroom. On a positive note most of the radiator have now been covered so as to prevent access to hot surface temperatures. The home has a lawn and car park to the rear of the property. It was noted that the home was much cleaner than at the time of the previous inspection, this no doubt in part due to the employment of a cleaner by the new owner. This included the laundry, which was far less cluttered than previously seen, with cleaning materials now stored separately in a locked cupboard. The home was seen to have policies and procedures in place in respect of infection control. A number of staff do need to have training in infection control however. Abbeymere Care Centre DS0000024951.V279024.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29,30 There are sufficient staff available to meet the needs of the residents with over half trained to an acceptable level in terms of vocational qualification. There are some areas where the manager/provider have identified training needs. Residents are supported and protected by the homes recruitment practices. EVIDENCE: The staffing levels on the day of the inspection were satisfactory, as the home did not have 100 occupancy. Based on observation and sight of the staff rota there are two care staff available during daytime with the manager/senior and ancillary staff additional to this. There is also a domestic that has been employed since the last inspection. There is currently two waking night staff, this confirmed by comments from residents. Whilst in terms of the staffing available the home was meeting standard 27, there was comment from relatives as to residents been sent to hospital without escorts, this a cause for some concern. It is not known as to whether these concerns pre dated the change of ownership. The home has employed one staff member since the last inspection and an audit of the recruitment checks was carried out, these found to be acceptable with a disclosure obtained prior to the date the staff member commenced work at the home. Disclosures were seen for all but one member of staff, with a clear POVA check available in this instance. This person was employed prior to Abbeymere Care Centre DS0000024951.V279024.R01.S.doc Version 5.1 Page 18 the last inspection and has remained under close supervision through their induction period, some of this evidenced in writing. It was agreed at the time of the inspection that a copy of the homes training plan would be forwarded to the CSCI for assessment. At the time of writing this had not been received and must be forwarded. It is was stated by the manager that over 50 of the staff team have an NVQ level 2, this partly evidenced by certificates, although three staff were stated to be waiting for theirs to arrive after recent completion of the same. Abbeymere Care Centre DS0000024951.V279024.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33, 35, 36, 37, 38 Residents live in a home that is run by a provider of good character and the ability to discharge his responsibilities fully. The manager is in need of further training in management however. Systems to measure how the home will be run in the best interests of the residents are planned. The procedures for the safekeeping of resident’s valuables could be improved. Supervision of staff has improved since the last inspection. The homes policies and procedures are in need of review in light of recent changes in ownership of the home. Risk assessment in respect of safe working practices needs to be improved to assist with the promotion of residents’ health, safety and welfare. Abbeymere Care Centre DS0000024951.V279024.R01.S.doc Version 5.1 Page 20 EVIDENCE: The manager has been employed at the home for a number of years and has much experience of working with the elderly. Her qualifications do not however include the management aspect of NVQ level 4, only the care element. This training must be provided. Concerns as to the support of the manager have now been alleviated as the new provider has a wealth of experience in social care and meets the requirements of registration as a manager in respect of his other home. It was clearly indicated in discussion with the provider and manager that the former has clear expectations of the latter, who did confirm the improved level of support that she was now receiving. Whilst the home does not have a fully operational, and professionally recognised quality assurance system in operation at this time, the provider was able to evidence that steps were been taken to remedy this, with a model of the system to be possibly adopted shown to the inspector. It was pleasing to find from discussion with residents that they were clearly aware of whom the new provider was, this underlining that he has communicated his presence in a relatively short space of time. Comments received about him and the manager from the residents were of a positive nature. A staff meeting has been held shortly after the new provider took over the home and these must continue to take place regularly and staff sign to say they have attended. Staff supervision on a one to one basis has commenced (some records of the same seen) but must continue to ensure care staff receive a documented supervision session at least six times every year. One supervision session per annum maybe a training analysis/appraisal for individual staff. The home was seen to safekeep small amounts of some resident’s monies, these appropriately stored and when spot checked found to balance with appropriate kept records, with the exception of one that was a penny over. The home has a hardback book with details of resident’s property recorded within it, although this did not include details of resident’s clothing. Policies related to residents finances and related areas would benefit from review (see comment below) There were some gaps in record keeping that have been identified within this report, and there is a need to review all the homes policies and procedures in light of the recent change in ownership of the home, this to ensure that the expectations of the new owner are clear and that any gaps in current policies are filled. Safety checks carried out on equipment and the house were examined and found to be in order with the exception of a test of the homes water supply for Abbeymere Care Centre DS0000024951.V279024.R01.S.doc Version 5.1 Page 21 legionella. The way the staff record accidents was seen to have been revised, these now documented on pre printed sheets. As stated earlier in this report individual risk assessments need to be improved and risk assessments in respect of safe working practices need expansion, this as identified in the last Environmental Health Officers report. Abbeymere Care Centre DS0000024951.V279024.R01.S.doc Version 5.1 Page 22 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 2 2 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 4 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 2 2 2 2 Abbeymere Care Centre DS0000024951.V279024.R01.S.doc Version 5.1 Page 23 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(1) Requirement To continue to develop the care plans so that they identify clear action to ensure that all aspects of the resident’s health, personal and social care needs are being met. These (plans) must be drawn up with the resident or their representative who must sign to acknowledge their agreement. This requirement is repeated in part. Risk assessments in respect of 28/02/06 any hazards related to individual residents must be improved, or in cases put in place to cover any significant risks identified such as: - Use of cot sides - Choosing not to be checked by night staff. - Falls - behaviours etc. To ensure that all medications 04/01/06 are signed out at the point of administration and the records of this administration are complete and up to date with any DS0000024951.V279024.R01.S.doc Version 5.1 Page 24 Timescale for action 31/03/06 2. OP7 13(4) 3. OP9 13(2) Abbeymere Care Centre 4. OP9 13(2) 5. 6. OP9 OP9 13(2) 13(2) medication prescribed to an individual fully documented on the record. To ensure that there is always 04/01/06 sufficient medication in stock so that the home does not run out of prescribed medication To ensure that there is no 04/01/06 medication loose outside of a labelled container. The home must continue to liaise 15/02/06 with the appropriate G.Ps to ensure that there are specific directions for the administration of all service users medication. This is a repeated requirement. To supply the CSCI with a copy of the last audit carried out by the contracted pharmacist. The homes procedure for ordering of medication must be reviewed. To continue developing the activities programme for the home in consultation with service users. This must be regularly reviewed. 15/02/06 28/02/06 31/03/06 7. 8. 9. OP9 OP9 OP12 13(2) 13(2) 4 &16 10. 12. OP18 OP18 13(6) 37 13. OP19 13 (4) & 23 Service users interests must be recorded and where possible residents must be supported and encouraged to pursue stimulation in and outside the home, which suits their needs, preferences and cultural interests. Inventories of resident’s property 31/03/06 must be expanded so as to include residents clothing. To ensure that any incidents 04/01/06 arising from altercations between residents are reported to the CSCI without delay. To continue with the homes 31/03/06 programme of refurbishment and redecoration and to include within this: DS0000024951.V279024.R01.S.doc Version 5.1 Page 25 Abbeymere Care Centre Repair to the areas of rust on the upstairs bath. Reaffixing the carpet downstairs by the lift where a tripping hazard is present. To investigate the inconsistencies in heating in differing areas of the home. 14. 15. 16. OP26 OP30 OP33 13(3) 18 24 To address the urine related odour in Room 1. To forward a copy of the homes training plan to the CSCI. The home must continue to implement a quality assurance and monitoring system based on the views of service users. To continue implementing a formal supervision system, ensuring care staff receive a documented supervision session at least six times every year. To review all the homes policies and procedures in light of the recent change in ownership of the home. To complete risk assessments relating to hazards within the home as identified in the last Environmental Health Officers report. 28/02/06 15/02/06 30/04/06 17. OP36 18 31/12/06 18. OP37 10 31/03/06 19. OP38 13(4) 28/02/06 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 OP1 OP2 Good Practice Recommendations To review the homes statement of purpose against the requirements of the care home regulations 2001. To review the home terms and conditions so as to remove potentially unfair conditions. DS0000024951.V279024.R01.S.doc Version 5.1 Page 26 Abbeymere Care Centre 3. 4. 5. OP9 OP31 OP32 To ensure the shelves in the medication cupboard are kept clean. The manager must commence and attain a qualification in management equivalent to the Registered managers Award (NVQ level 4 in management) Staff meetings must continue to take place regularly and staff sign to say they have attended. These must be recorded and kept on file. Abbeymere Care Centre DS0000024951.V279024.R01.S.doc Version 5.1 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: 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 Abbeymere Care Centre DS0000024951.V279024.R01.S.doc Version 5.1 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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