Inspection on 27/07/07 for Abbeymoor Care Home

This inspection was carried out on 27th July 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

Abbeymoor Care Home 17/09/09

Abbeymoor Care Home 28/11/08

Abbeymoor Care Home 30/06/08

Abbeymoor Care Home 19/10/06

Abbeymoor Care Home 31/01/06

Abbeymoor Care Home 16/08/05

Abbeymoor Care Home 19/10/04

Abbeymoor Care Home 21/04/04

Similar services:

Trevayler Residential Care Home

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

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

CARE HOMES FOR OLDER PEOPLE Abbeymoor Care Home Sherwood Road Worksop Nottinghamshire S80 1QW Lead Inspector Rob Cooper Unannounced Inspection 10:00 27th July 2007 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 Abbeymoor Care Home DS0000059941.V340647.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. Abbeymoor Care Home DS0000059941.V340647.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbeymoor Care Home Address Sherwood Road Worksop Nottinghamshire S80 1QW 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) 01909 475660 01909 480998 Care Companions Healthcare Ltd Vacant Care Home 25 Category(ies) of Dementia - over 65 years of age (19), Mental registration, with number disorder, excluding learning disability or of places dementia (6), Old age, not falling within any other category (19), Physical disability over 65 years of age (19), Terminally ill (19) Abbeymoor Care Home DS0000059941.V340647.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4 of the beds may be used for service users over the age of 60 years There will be a Lead, Head of care, for the eating Disorders unit on site between the hours of 08:00 and 18:30 MD Category can only be used for Younger adults (Eating Disorder) age 18 to 65 19th October 2006 Date of last inspection Brief Description of the Service: Abbeymoor is a care home that provides residential, nursing and specialist care to adults from the age of eighteen. There are 25 places and services are offered to both female and male residents. The care home is registered to provide specialist care and support for up to six adults between the ages of eighteen and sixty-five, and 19 places for older people, people with dementia and people with a physical disability over 65 years. Six beds provide a specialist Younger Adult unit for women and men who have a diagnosed Eating Disorder. The home can offer short term and long term residential/nursing care. Abbeymoor is located close to shops and local services (about 500 metres) and there is access to public transport including a train station (about 500 metres). The home is detached and set in its own grounds with a car park to the front of the building. The building is adapted to cater for the needs of people with mobility problems and all areas within the home are accessible, with a shaft lift to each of the three floors. The Younger Adult unit has its own newly installed kitchen, dining and lounge area, separate from the communal facilities offered to service users residing within the main building of the care complex. The fees range from £283 per week for residential care to £351 with £83 nursing top up per week for residents receiving nursing care. Abbeymoor Care Home DS0000059941.V340647.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 visit as part of the key inspection process – so that no one at Abbeymoor knew that the inspection visit was going to take place. The visit took approximately three and a half hours through the middle of the day, with one inspector present. The method used to carry out this key inspection visit was to send out a preinspection questionnaire, which asked questions about the service, to gather statistics, such as how many service users there are, the numbers of staff etc. We also sent out a number of surveys to residents and relatives, and sent Abbeymoor an Annual Quality Assurance Assessment (known as an AQAA) for them to self assess their service. This was followed with a visit to Abbeymoor, where a method called case tracking was used; this involved identifying three residents and looking at their individual files and making a judgement about the quality of care they are receiving, and if their needs are being met. This was done by a partial tour of Abbeymoor, looking at the activities on offer, and talking to two residents and three members of staff about the quality of the service, and their experiences of living and working at Abbeymoor. Currently Abbeymoor does not have a registered manager in post, and therefore members of the qualified nursing team supplied much of the information during the visit. On the day of this inspection there were thirteen residents in residence. Prospective residents can obtain information about Abbeymoor direct from the care home, and this would include seeing previous inspection reports prepared by the Commission for Social Care Inspection. Care Companions also have a web site at: www.carecompanions.co.uk although this provides information only about the eating disorder unit, and not the elderly care provided at Abbeymoor. What the service does well: What has improved since the last inspection? Abbeymoor Care Home DS0000059941.V340647.R01.S.doc Version 5.2 Page 6 Nurses working at Abbeymoor have their professional details recorded in their personal files, and the lift has been serviced, and has a safety certificate. Residents are now signing their care plans to show their agreement. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Abbeymoor Care Home DS0000059941.V340647.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 Abbeymoor Care Home DS0000059941.V340647.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): 13&6 Quality in this outcome area is good; this judgement has been made using available evidence including a visit to this service. Prospective residents at Abbeymoor had sufficient information before they moved in to make an informed choice about where to live. Currently residents are well informed about the services Abbeymoor offers Abbeymoor does not offer intermediate care. EVIDENCE: The service user guide and statement of purpose for Abbeymoor were both seen, and these provided a good overview of the service being offered at Abbeymoor. The service user guide had been reviewed in January 2007, but needs further review, as the details of the registered manager are incorrect. Two residents were asked whether they had a copy of the service user guide, Abbeymoor Care Home DS0000059941.V340647.R01.S.doc Version 5.2 Page 9 but neither was sure. Staff members said that residents had been given a copy of the service user guide, although none were evident in the bedrooms. As part of the case tracking process three resident’s files were seen. Each file contained an assessment of need, which had either been completed in-house, or had a Shared Nottinghamshire Assessment Profile - A SNAP (which is the latest assessment form for older people used within Nottinghamshire) or transfer information depending on where the resident had been prior to moving in to Abbeymoor. There was evidence that the assessments had been completed prior to admission, and that the resident’s care needs had been based upon the assessments. Abbeymoor Care Home DS0000059941.V340647.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 & 11 Quality in this outcome area is good; this judgement has been made using available evidence including a visit to this service. The residents have their health and personal care well managed, supported and recorded by the staff at Abbeymoor. EVIDENCE: The resident’s files contained a good selection of care plans aimed at meeting their needs, and evidence was seen that care plans had been reviewed within the last month – as recommended by the National Minimum Standards. Of the three files seen, two residents had signed their care plans to show their agreement; while a third had made a verbal agreement, as they were unwilling to sign the plans. All of the files that were seen contained care plans related to resident’s health care needs, and these were clear and detailed. Two residents were asked about seeing their doctor, and they said that they had a local doctor who came to see them at Abbeymoor (arranged through the staff) if they needed. Health Abbeymoor Care Home DS0000059941.V340647.R01.S.doc Version 5.2 Page 11 related records – for example visits by the GP or other health professionals were recorded within the individual’s care files. A local Chemist provides Abbeymoor with their medication. An inspection of the storage, and booking in and out procedures showed that medication is handled safely and there is a clear audit trail for medication from the point of ordering to administration and/or disposal. Administration records were inspected and found to be complete. No resident at Abbeymoor currently selfmedicates. Discussions with staff indicated that the local chemist had not provided any ‘refresher’ training for staff around medication, despite this being a requirement for the chemist under the terms of the contract. This should be followed up with the chemist directly. During the course of the inspection visit a number of staff to resident interactions were observed. These were seen to be polite and respectful, and staff were observed knocking on resident’s doors before entering. Two residents were spoken with during the inspection, and each one said that they thought the staff treated them well. One saying: “The staff are very good, very kind” while a second when asked about staff said: “Yes – they are marvellous.” Each of the three care files that were seen contained information relating to the last wishes of the individual resident. This included whether they wished to be buried or cremated, who was handling the arrangements, and whom they would want notified at the time of their death. Abbeymoor Care Home DS0000059941.V340647.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. Residents at Abbeymoor have a lifestyle that reflects their cultural, social and religious interests, and needs. Choice for residents is limited, and record keeping of any choices made is poor. EVIDENCE: Activities for residents are arranged in a fairly informal manner, with no weekly programme of activities in evidence. In the Annual Quality Assurance Assessment, Abbeymoor’s proprietors stated that: “we have external entertainers” however the evidence showed that this was on an occasional basis, and there were no posters on display advertising any forthcoming events. In-house Bingo appeared to be very popular, although there is no activity co-ordinator employed to organise activities, so the care staff arrange this. A review of the staffing rota showed a number of occasions when staffing levels were low, and staff said that care took precedence over the social activities at these times. Three residents were asked about activities, one was busy making tapestries, an activity that he really enjoyed, but which required minimal staffing input, while the other two said that they joined in when Abbeymoor Care Home DS0000059941.V340647.R01.S.doc Version 5.2 Page 13 something was arranged if they felt like it. There remains an outstanding requirement in relation to consultation with residents over a programme of activities, as no evidence of any consultation was seen. Unfortunately it was not possible to speak with any relatives during the inspection visit, but both residents who were spoken with said that their families were able to visit when they liked, and that the staff made them very welcome. At the last key inspection a recommendation was made relating to the policy on sexuality being more detailed and staff having training and support on issues of the sexuality of residents. No evidence was seen to show that this had happened, and two members of staff who were asked about specific training indicated that they had not received any. Two residents were asked about choice, and both said they felt that they had opportunities to exercise choice, from deciding what time they went to bed, through to making a choice over what to eat for lunch. The menu for the day had a choice between fish and chips, or cold meat. The daily menu was displayed on the notice board, but the writing was very small. It would be beneficial to residents to display the menu in a large print, to help them make choices. There is a resident’s comments box, although this was empty on the day of the inspection visit, and staff said that it was very rarely if ever used. The kitchen at Abbeymoor is well equipped, and there were good supplies of food, including fruit and vegetables. However there was no recorded menu, which would show what is for lunch tomorrow or the day after and that is available to residents. There is also no formal recording of residents’ meal choices and the alternatives provided, and therefore no real evidence with regard to the choices people had actually made, or the information they had to help them make those choices. Abbeymoor Care Home DS0000059941.V340647.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. There is no evidence that resident’s complaints are taken seriously and dealt with. Residents at Abbeymoor are potentially unsafe due to the lack of staff training in safeguarding adult’s procedures. EVIDENCE: Abbeymoor’s last recorded complaint was on the 26th June 2003. The complaint’s procedure is on display on the notice board, but is not prominently displayed, or a document that readily attracts the reader’s attention. The complaint’s procedure does form part of the statement of purpose and service user guide, but as has already been stated, there was no evidence that residents had received copies of these documents. A requirement set at the last key inspection is therefore still outstanding. In the Annual Quality Assurance Assessment, Abbeymoor’s proprietors stated that: “A high standard of care and interest in the well being of residents means that we have a very low level of complaints.” The evidence would suggest that residents and relatives are unsure of how to complain, or whom to complain to, and this may have affected the number of potential complaints received. Discussions with members of staff and a review of staff training records showed that the majority of staff have not received training in safeguarding adults, or that if they have the training is in need of updating. This training is a crucial tool in protecting residents from abuse, as it raises awareness, and Abbeymoor Care Home DS0000059941.V340647.R01.S.doc Version 5.2 Page 15 informs staff of the action to take if they suspect that abusive behaviour is occurring. This lack of up-to-date training in safeguarding adult’s procedures for all staff leaves residents potentially at risk. Abbeymoor Care Home DS0000059941.V340647.R01.S.doc Version 5.2 Page 16 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. Residents at Abbeymoor live in a safe, clean and comfortable home, with their personal possessions around them. EVIDENCE: A partial tour of Abbeymoor showed it to be comfortable and well maintained, with good quality fixtures and fittings. The lounge is spacious and light, with a conservatory attached. Bedrooms are of a good size, many with en-suite facilities, and there is a lift to help those with restricted mobility access all parts of the home. Abbeymoor also have adapted bathing facilities to assist those who need additional help in the bath. Outside there are pleasant sitting areas, and a car park for visitors to use at the front. Abbeymoor Care Home DS0000059941.V340647.R01.S.doc Version 5.2 Page 17 Staff were seen cleaning in various areas of Abbeymoor during the inspection, and the building was found to be clean. Two residents were asked about the cleanliness, and both said that they thought the staff worked hard to keep the home clean and tidy. Abbeymoor Care Home DS0000059941.V340647.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27 28 29 & 30 Quality in this outcome area is adequate; this judgement has been made using available evidence including a visit to this service. Staff at Abbeymoor have been recruited professionally, although procedures need to be improved. There was insufficient evidence to support the view that staff working at Abbeymoor are competent and trained to do their jobs. EVIDENCE: A review of the staffing rota showed a number of occasions in the last four weeks when staffing levels dropped to only two people on duty. The assessed needs of the residents more than suggest that this is not adequate. Three members of staff who were asked said that on occasions they thought there was not enough staff. A requirement made at the last key inspection around staffing levels has not been met. In the Annual Quality Assurance Assessment, Abbeymoor’s proprietors stated that: “Regular bank staff were used to cover nursing care.” However staff said that sickness and absence were covered internally, and staff do not use an Agency, or external provider. The recommended standard training course for staff working in care is the National Vocational Qualification (NVQ) level II. Of the nineteen staff members on the team, six people have their NVQ level II, and one person is currently waiting to start. In addition one member of staff has their NVQ level III qualification. There are also eight qualified nurses working at Abbeymoor. Abbeymoor Care Home DS0000059941.V340647.R01.S.doc Version 5.2 Page 19 Ideally there should be 50 of the staff team qualified to a minimum of NVQ level II, and this has been achieved. Three staff files were seen, and these should contain all of the information that would show that staff had been recruited in a safe manner – in that applicants had to fill out an application form, provide two written references and undergo a Criminal Records Bureau check. A review of the documentation showed that One file had all of the necessary documentation, while the other two were lacking in references. The Care Standards Act (2000) – Schedule 2 requires that two written references be obtained for every member of staff. A review of the staff training records showed that Abbeymoor does not have a viable training plan for its staff. There was evidence of some staff training courses planned for the coming months, but there was no evidence of an overall staff training plan, and discussions with staff members indicated that some of the training they had undertaken had not been updated. Mandatory training courses in fire, moving and handling, safeguarding adults etc should be updated on an annual basis, there was however no evidence to support the view that this is happening. Abbeymoor Care Home DS0000059941.V340647.R01.S.doc Version 5.2 Page 20 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. Abbeymoor is a potentially unsafe care home due to the inadequate recording of the Legionella testing. Abbeymoor is also not necessarily run in the best interests of its residents. EVIDENCE: The registered manager at Abbeymoor left recently, and there is currently no on-site manager to oversee the service. The proprietor is managing the service by frequent visits from his home in London. This is a short-term measure, and a registered manager should be recruited at the earliest possible opportunity. Abbeymoor Care Home DS0000059941.V340647.R01.S.doc Version 5.2 Page 21 Currently resident’s meetings do not take place at Abbeymoor, and these should be introduced to ensure that residents have a formal voice, and the opportunity to comment on the quality of care they are receiving. Regulation 26 visits by the provider (monthly visits to review the quality of the service) are taking place, and several ‘reports’ were seen. There was no evidence that the full quality audit recommended at the last key inspection has taken place, so this recommendation will remain. Resident’s at Abbeymoor have a small cash needs system for their personal cash needs. This is operated on their behalf by the staff, and four resident’s finances were sampled at random and checked. All cash balances tallied with the records, and receipts were kept, which enabled a clear audit trail of resident’s expenditure. Abbeymoor operates a supervision system, with staff having formal supervision approximately six times a year. Records relating to the staff’s formal supervision were seen and these indicated that staff members were properly supervised. Three staff members were spoken with about supervision and said that they were having a formal supervision session approximately every eight weeks. Many different health & safety records were seen, including the fire safety records – weekly tests, emergency lighting tests and extinguisher maintenance records, all were found to be correct and up-to-date, which evidenced that the residents and the staff are living and working in a safe environment. However weekly testing for Legionella is being carried out, but the recording does not fully indicate which taps have been tested. This is particularly important as Abbeymoor have a number of vacant rooms, where there is an increased risk of Legionnaires disease. A requirement made at the last key inspection in relation to servicing of the lift and the nurse call system had been adequately dealt with. Abbeymoor Care Home DS0000059941.V340647.R01.S.doc Version 5.2 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 3 X 2 Abbeymoor Care Home DS0000059941.V340647.R01.S.doc Version 5.2 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 OP1 Regulation Requirement Timescale for action 15/09/07 2. OP12 Regulation The statement of purpose and 6 service user guide must be reviewed, so that the information contained within both documents is accurate and up-to-date. 31/08/07 Regulation Residents must be consulted 16 with about their programme of activities and facilities for recreation and leisure must be provided. This is an outstanding requirement from the last key inspection. Regulation Residents and relatives must be 13 made aware of their right to complain and the process to follow if they have any complaints or concerns. This is an outstanding requirement from the last key inspection. Regulation Training on safeguarding Adults 18 procedures must be provided to all staff. Regulation Staffing levels must be increased 18 to a level where there are enough staff on duty throughout the day to meet the assessed DS0000059941.V340647.R01.S.doc 3. OP16 30/09/07 4. 5. OP18 OP27 31/12/07 31/08/07 Abbeymoor Care Home Version 5.2 Page 24 needs of the residents, and to ensure their safety and welfare. This is an outstanding requirement from the last key inspection. Regulation Every member of staff working 19 at Abbeymoor must have all of the documentation outlined in Schedule 2 of the Care Standards Act (2000) in their personal file. This will include two written references, and these should be obtained no matter how long the individual has been in post. Regulation Staff working at Abbeymoor 18 must receive training in the mandatory areas, and have an annual update to ensure that they are aware of the latest/ best practice. Regulation A registered manager to oversee 8 the day-to-day operation of Abbeymoor must be appointed as soon as possible. 6. OP29 30/09/07 7. OP30 31/12/07 8. OP31 31/12/07 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. Refer to Standard OP1 OP9 OP13 OP14 Good Practice Recommendations Every resident should have an up-to-date copy of the service user guide, and evidence that they have received a copy should be kept in the individual’s care file. The local chemist who supplies Abbeymoor with their medication should be contacted about providing staff training and updates. The policy on sexuality should be more detailed and staff should be given training and support on issues of the sexuality of residents. The daily menu should be displayed in a more prominent DS0000059941.V340647.R01.S.doc Version 5.2 Page 25 Abbeymoor Care Home 5. 6. 7. 8. OP15 OP30 OP33 OP33 9. OP38 position, and in larger print, so that residents can have a better idea of what is being offered for lunch. There should be a recorded menu, which is displayed and available to residents and formal recording of residents’ meal choices and alternatives provided. The registered person should undertake a full audit of staff training and skills to ensure statutory requirements are met and that staff are competent to undertake their role. Formal residents meetings should be introduced to give residents the opportunity to express their views, and to comment on the care they are receiving. The registered person should undertake a full quality audit on the service incorporating residents’ views a minimum of annually. These results should be collated and made available. The recording system for the weekly Legionella testing should be developed so that it indicates every tap that is tested. The recording system should also indicate which rooms are empty, as there is an increased risk of Legionella in these rooms. Abbeymoor Care Home DS0000059941.V340647.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN 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 Abbeymoor Care Home DS0000059941.V340647.R01.S.doc Version 5.2 Page 27 - 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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