Inspection on 30/06/08 for Abbeymoor Care Home

This inspection was carried out on 30th June 2008.

CSCI found this care home to be providing an Poor service.

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 27/07/07

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 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Abbeymoor Care Home Sherwood Road Worksop Nottinghamshire S80 1QW Lead Inspector Stephen Benson Unannounced Inspection 30th June 2008 09:00 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 Abbeymoor Care Home DS0000059941.V367417.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.V367417.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 Manager post 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.V367417.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 27th July 2007 Date of last inspection Brief Description of the Service: Abbeymoor is a care home that provides residential 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 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 is currently not staffed or operational. The fees start from £338 per week but the higher rates were not known in the home. The last key inspection report was in the office but there was not a copy of the two random inspection reports from 11/01/08 and 22/05/08. Abbeymoor Care Home DS0000059941.V367417.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. This means the people who use this service experience poor quality outcomes. This was our second visit to the home since 1st April 2008. This inspection involved one inspector; it was unannounced and took place in the daytime, including lunchtime. Prior to the visit an analysis of the home was undertaken from information gathered over the last year including that from the Annual Quality Assurance Assessment they completed. We sent survey forms entitled ‘Have your say about…’ to a sample of people, but none of these were returned. The main method of inspection used is called ‘case tracking’ which involves looking at the quality of the care received by a number of people living at the home. We also use evidence from our observations; we speak with them about their experience of living at the home; we look at records and talk with staff about their understanding of the people’s needs who they support. The premises were not inspected in detail but various areas of the home were visited as part of the inspection. What the service does well: Although there has not been anyone new admitted to the home for some time there is sill a system in place to go out to assess anyone considering coming to the home to assess whether their needs can be met. We saw that people’s healthcare was being properly attended to and checks being made to make sure that they do not get any worse. People are given their medication in a safe way and time is being taken to make sure that staff learn how to do this properly before they start to give medication out. There is a complaints procedure, which is available for people to use. There was information seen that told staff what they must do in order to make sure people are safeguarded and staff are leaning about what they should do if they needed to ensure someone’s safety. Abbeymoor Care Home DS0000059941.V367417.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The 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.V367417.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.V367417.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): 1, 3 and 6 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Anyone being assessed to come to the home would not have accurate information about what is provided at the home. EVIDENCE: There was a Statement of Purpose, which was revised in June 2008. This stated the services provided by the home, although these are not all currently in place. For example the list of activities provided include activities that have never been provided and some that have not been provided for a number of years. Information provided on The Annual Quality Assurance Assessment (AQAA) stated that there have been 2 people admitted to the home in the last 12 months for short term care. Abbeymoor Care Home DS0000059941.V367417.R01.S.doc Version 5.2 Page 9 The records for these admissions have been archived so were not available to look at. The lead nurse said one of the nurses would go out to assess any prospective new resident and showed an assessment pro forma that would be used. Staff said they could not remember the last time a new person came to the home. There is no arrangement made for the home to provide an intermediate care service. Abbeymoor Care Home DS0000059941.V367417.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 and 10 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The care planning system does not benefit people living in the home resulting in some needs being met and others overlooked. EVIDENCE: It was stated on the Annual Quality Assurance Assessment that it is planned to check with people on a weekly basis if they need any changes to their plans and that a more personalised service can be provided with only five residents. A sample of three care files were looked at. These contained care plans which had been reviewed, usually on a monthly basis. The files were somewhat disorganised and contained a lot of old and outdated information. Abbeymoor Care Home DS0000059941.V367417.R01.S.doc Version 5.2 Page 11 New care plans had been put in for recent changes in people’s health, although the other care plans had not been updated to take into account the effect the changed has on those, for example one person living in the home had a problem with her legs and the new care plan described the care needed for this but the care plan for mobility had not been updated to reflect this. There were some details seen in care plans, which did not relate to the subject of the plan. For example a care plan for sexuality included ‘to be given a choice of food’. There were references in care plans to providing people with choices and promoting their privacy and dignity. The lead nurse said that when she was updating the care plans she had noted that they needed tidying up and intended to do this when she had some time. Staff said they have now started to write in care plans and are getting more involved in them. A person living in the home said, “I am asked what I can do, I still do some things myself”. The daily notes made showed the well being of people living in the home was monitored. There was one person living in the home who had become poorly recently. This was reported on in the daily notes as well as the actions taken. A doctor had been called out and came to visit the resident. There were appropriate monitoring charts in the person’s room showing the fluid intake and that the person was not allowed to stay in one position for too long. The lead nurse said that they observe the people living in the home and do what is needed to promote their health. An emergency dental appointment had been made recently for one person. Staff said they know the people living in the home so well they can notice if they are not feeling well. A person living in the home said, “I feel my health is well looked after, I see a doctor if I need to”. There have been recent proposed changes to the home’s medication procedure. It was intended for care staff to share in the administration of medication. As a result there was a requirement set at a random visit on 22nd May 2008 that the medication policy must be updated. Staff are in the process of being trained to administer medication, however as the change has not yet Abbeymoor Care Home DS0000059941.V367417.R01.S.doc Version 5.2 Page 12 taken place the current policy remains valid, but will need to be updated prior to any change occurring. Part of the morning medication round was observed and the lead nurse did this, with the care staff on duty observing. Medicine Administration Records seen were fully completed. The lead nurse said that the training of care staff to give out medication is ongoing but in the meantime she is on call to come to the home to administer any medication if needed if another trained person is not on duty. Staff said they are being trained to give out medication and that it is a big responsibility but they are getting used to it now. Staff said they are not being rushed to start giving out medication. A person living in the home said, “The nurses give me my medicine”. Staff were seen using a toilet chair to take a person from the lounge into the toilet. When discussed with staff they said it was the only way they could take the person to the toilet, however after a discussion agreed that this was an undignified practice and that they would consult with an Occupational Therapist (OT) to seek an alternative. Staff said they provide personal care in private with doors closed. A person living in the home said, “I am happy with how staff help me”. Abbeymoor Care Home DS0000059941.V367417.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in the home are not having their social and dietary needs met to an acceptable standard and are being placed at risk through poor catering practices. EVIDENCE: The minutes of a residents, meeting showed that people living in the home had been asked what activities they would like to take place in the home, but had not yet had an opportunity to put these forward. There were activities sheets showing that some form of activity is offered daily, but this does not show who took part. The administrator prepared a new activities form so this could be done from now on. Abbeymoor Care Home DS0000059941.V367417.R01.S.doc Version 5.2 Page 14 Examples of activities provided were watching television or a film, having hair and nails done, chatting, attending a Sunday service, playing cards, music and singing and chatting. The lead nurse said she has been asked by people living in the home for the gazebo to be put up so they can sit outside in he nice weather, but this has not been done yet. Staff said one person living in the home is being encouraged to knit and read again after having stopped for a while. Staff said some people living in the home like to watch sport and cowboy films. A person living in the home said, “I would like to have more to do than just watch television”, but when asked what sort of things was unable to make any suggestions. Staff said that visitor are welcome to visit at anytime, but people living in the home are not interested in going out. A person living in the home said, “My family come to see me”. Staff said that people living in the home are able to make choices about anything. They are able to choose their own daily routine, including when they get up, go to bed and have a bath or shower. One person living in the home was seen in charge of the remote control for the television and changing programme without consulting others. Another person living in the home was asked if he minded and said, “I watch anything me”. There were other televisions available to watch. It was stated on the Annual Quality Assurance Assessment that we record wishes for residents’ food and individualised meals to suit are provided. The main meal is at lunchtime. There is not a menu in use and there is a sheet to record meals on but these were rarely dated making it difficult to see what meals have been provided. Meals recorded were repetitive with shepherds pie, corned beef hash, stewing meat, chicken and fish pie occurring regularly. The cook said she would do more but has to decide what to cook according to what there is in the freezer. There was no record of any alternative or special diet being catered for. The cook said she didn’t know she was meant to record anything different provided from the main meal. Abbeymoor Care Home DS0000059941.V367417.R01.S.doc Version 5.2 Page 15 Lunch today was cold chicken, chips and mushy peas. This was seen plated up in the hotplate prior to the meal being served. As a result the cold chicken (which was left over from yesterdays Sunday lunch) was being heated up. There was a pudding of bread and butter pudding with custard. There was also one person living in the home who requires a soft diet who was provided with mashed potato, vegetables and gravy. This was all from leftovers from yesterday’s lunch. There was a chest freezer, in use, which did not close properly leaving a gap of approximately 2 centimetres. (This had been noted at the previous inspection). There was a frying pan seen in the larder with previously used lard in. Three people living in the home were asked if they had enjoyed their lunch and all said yes they had. Abbeymoor Care Home DS0000059941.V367417.R01.S.doc Version 5.2 Page 16 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 and 18 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are systems in place for people living in the home to raise complaints and protect people from abuse, although these have not been used. EVIDENCE: Information provided on The Annual Quality Assurance Assessment showed that there have not been any complaints made in the last 12 months. There was a copy of the complaints procedure included in the Statement of Purpose, which was on the notice board. Staff were aware of the complaints procedure and said if someone says something they are able to deal with they will do so. A person living in the home said, “I’ve not got any complaints”. Information provided on The Annual Quality Assurance Assessment showed that there have not been any safeguarding referrals made and no safeguarding investigations have taken place. There have not been any referrals made to the Protection of Vulnerable Adults list. Abbeymoor Care Home DS0000059941.V367417.R01.S.doc Version 5.2 Page 17 The lead nurse showed the Nottingham and Nottinghamshire Safeguarding Adults Policy, Procedure and Guidance for Alerters and Referrers The lead nurse said that all staff were reading through the procedures an d there was a training record in the training file for them to confirm each section they have read. The lead nurse said there will be training provided at a later date. There was a notice in the office stating that the lead nurse will be providing training on safeguarding adults. Staff confirmed they were reading the procedures and recording when they have done so. A person living in the home was asked if he felt safe in the home and replied ”yes”. Abbeymoor Care Home DS0000059941.V367417.R01.S.doc Version 5.2 Page 18 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 and 26 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home and grounds are poorly maintained and do not offer a comfortable, and pleasant environment for people to live in. EVIDENCE: It was stated on the Annual Quality Assurance Assessment that areas of the home have been decorated and some carpets have been cleaned. There were a number of carpets seen that were in need of cleaning or replacement as they were marked and showing signs of wear. Some carpets were not tightly laid to the floor. Abbeymoor Care Home DS0000059941.V367417.R01.S.doc Version 5.2 Page 19 There are some areas of the home not currently used due to the occupancy level. Some of the occupied areas are in need of decoration. This includes the bathrooms and corridors. The lead nurse said one person living in the home had been moved to a ground floor room to help with his independence and mobility. This room was previously a shared room and still had two beds in. The person said, “I don’t mind the other bed for the time being but may want it out in the future”. The garden showed signs of neglect with grass and flowerbeds overgrown. Staff said that they are only using part of the building but they check the reminder. Some decoration is needed. A person living in the home said, “Some carpets look worn and stained, it would be nice to have new ones”. The lead nurse said that she is going on infection control training shortly. There is someone employed to clean the home and do the laundry. Staff said that there is protective clothing available and were seen using it. A person living in the home said, “I think the rooms are kept clean”. Abbeymoor Care Home DS0000059941.V367417.R01.S.doc Version 5.2 Page 20 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 and 30 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in the home are being cared for by staff who have not had all the training they require and may well be tired through working long shifts and extra hours. EVIDENCE: Information provided on The Annual Quality Assurance Assessment showed that there are 12 care and nursing staff employed. There have not been any shifts covered by agency staff in the past three months. The rota showed that there is one nurse and one care staff on duty during the day. One Nurse is currently on holiday, which has meant the other nurse was working eleven days without any time off. On some of the days the nurse is working both morning and afternoon shifts. The lead nurse said that she knew it was not an ideal situation but did not know what else to do. The lead nurse said there were telephone numbers of nurse agencies in case she became unavailable for work. Abbeymoor Care Home DS0000059941.V367417.R01.S.doc Version 5.2 Page 21 Staff said that everyone is doing extra shifts at the moment due to a lack of staff, but there is a new member of staff due to start this week. A person living in the home said, “There are always two staff on duty”. Information provided on The Annual Quality Assurance Assessment showed that there are 6 care staff who have National Vocational Qualification level 2 or above. A member of staff said she had completed National Vocational Qualification level 2. It was recorded on The Annual Quality Assurance Assessment that all people who have worked in the home in the past 12 months had satisfactory pre employment checks. Staff files seen did not have the identification documentation required. Information provided on The Annual Quality Assurance Assessment showed that all catering staff and 100 care staff have received training in safe food handling. It was also stated that the home has a staff development programme appropriate for the service they provide. The lead nurse said that staff have not had all the training they require, but she is trying to put this into place. Training records seen showed that there has not been recent training on basic food hygiene, infection control and moving and handling. There are training films for fire safety in care homes and first aid training is currently taking place. Staff said that they have not done much recent training, but felt able to do their job through their years of experience. Abbeymoor Care Home DS0000059941.V367417.R01.S.doc Version 5.2 Page 22 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 and 38 People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The lack of management arrangements mean that the home is not being run in the best interests of the people who live in the home and as a result they are not having the standard of service they are entitled to. EVIDENCE: There is not a registered manager recruited for the home and it was stated on the Annual Quality Assurance Assessment that they have failed to retain a nurse manager. One of the nurses has been given responsibility as lead nurse, but has not been allocated any time to attend to the management of the home. Abbeymoor Care Home DS0000059941.V367417.R01.S.doc Version 5.2 Page 23 As a result there was evidence of poor management found during the visit, which has been highlighted in this report. This includes a lack of activities organised and provided for people living in the home, a lack of food supplies to plan a balanced and wholesome diet, an inadequate and unsuitable meal being served and insufficient staff to cover the rota. Also the care plans were disorganised and not fulfilling their purpose. The lead nurse said she does not have the time to attend to management issues as she is one of two staff on duty and has to see to the needs of the people living in the home. The lead nurse showed the minutes of recent resident meetings where people living in the home have expressed concerns about the future of the home. The home will hold money for people living in the home to pay for hairdressing, chiropody and other incidentals. A record is made of each transaction and signed and witnessed. Receipts are kept when available. The lead nurse said that all the required health and safety checks are carried out at the required frequency and there are service contracts in place for servicing all the equipment. It was stated on the Annual Quality Assurance Assessment that equipment is tested or serviced as recommended by the manufacturers or other regulatory body. It was also stated that there are written assessments on hazardous substances. The lead nurse spoke of carrying out fire tests and running water outlets to prevent stagnant water. Abbeymoor Care Home DS0000059941.V367417.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 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 1 X 3 X 3 X X 3 Abbeymoor Care Home DS0000059941.V367417.R01.S.doc Version 5.2 Page 25 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 4(1) Requirement The Statement of Purpose must give an accurate reflection of the services provided within the home. This is to make sure that people who live in the home or who are considering moving there know what they can expect. All people using the service must have an up to date, detailed care plan that is kept in good order. This will ensure that they receive person centred support that meets their needs. People should receive any assistance in a way that maintains their privacy and dignity so people do not feel embarrassed or degraded Residents must be consulted with about their programme of activities and facilities for recreation and leisure must be provided. This requirement had a timescale Abbeymoor Care Home DS0000059941.V367417.R01.S.doc Version 5.2 Page 26 Timescale for action 01/09/08 2 OP7 15(1) 01/09/08 3 OP10 12(4)(a) 01/08/08 4 OP12 16(2)(n) 30/06/08 of 30/11/07, which has not been met. Enforcement action is now being considered 5 OP15 16 (2)(i) The current catering arrangements must be improved so there is sufficient and freshly cooked food to provide a healthy and varied diet that people who live in the home like. This will ensure that people have a variety of meals that they enjoy. This requirement had a timescale of 22/05/08, which has not been met. Enforcement action is now being considered 6 OP15 16 (2)(i) All food must be stored and prepared in a safe manner so that people are not placed at risk of food poisoning. This requirement had a timescale of 22/05/08, which has not been met. Enforcement action is now being considered 7 OP19 23(2)(d) The physical condition of the home and grounds must be improved so that people live in an environment they find pleasant and homely 18 (1)(a) There must be sufficient staff employed to provide the staffing level required to meet the needs of people who live in the home. 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 DS0000059941.V367417.R01.S.doc 30/06/08 30/06/08 01/02/09 8 OP27 01/09/08 9 OP29 30/06/08 Abbeymoor Care Home Version 5.2 Page 27 has been in post. This will ensure people living in the home are cared fro by people who are suitable to do so. This requirement had a timescale of 22/05/08, which has not been met. Enforcement action is now being considered 10 OP30 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. This will ensure that people living in the home are cared for by suitably trained staff. This requirement had a timescale of 22/05/08, which has not been met. Enforcement action is now being considered 11 OP31 Regulation A registered manager to oversee 8 the day-to-day operation of Abbeymoor must be appointed. This will ensure that there is someone accountable running the home in the best interest of the people living there. This requirement had a timescale of 22/05/08, which has not been met. Enforcement action is now being considered 12 OP31 18(1)(a) There must be suitable arrangements made, including designated time for the running of the home, whilst a new manager is recruited. This will ensure that people living in the home have someone managing the home in their best interests. DS0000059941.V367417.R01.S.doc 30/06/08 30/06/08 01/08/08 Abbeymoor Care Home Version 5.2 Page 28 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 Refer to Standard OP19 Good Practice Recommendations The person living in the home with an additional bed in his room should be given the opportunity for this to be removed Abbeymoor Care Home DS0000059941.V367417.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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.V367417.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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