Inspection on 19/05/05 for Abbeyrose Nursing Home

This inspection was carried out on 19th May 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Abbeyrose Nursing Home 07/07/08

Abbeyrose Nursing Home 22/01/08

Abbeyrose Nursing Home 13/09/07

Abbeyrose Nursing Home 29/08/06

Abbeyrose Nursing Home 22/11/05

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Abbeyrose Nursing Home 38 Orchard Road Erdington Birmingham B24 9JA Lead Inspector Ann Farrell Announced 19th May 2005 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 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. Abbeyrose Nursing Home E54_S61145_Abbeyrose NH_V220142_190505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Abbeyrose Address 38, Orchard Road,Erdington, Birmingham, West Midlands, B24 9JA, Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0121 377 6707 0121 373 9667 Dr Nazim Nathani MEB and Anand Concept Care Ltd NA Care Home with Nursing 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Abbeyrose Nursing Home E54_S61145_Abbeyrose NH_V220142_190505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1 Care home with nursing for a maximum of 25 service users for reasons of old age(OP). 2 The home can accommodate existing service users for reason of: Physical disability(PD) – 1 person, Mental disability(MD) 2 people 3 That a temporary nurse manager will be employed on a full time basis within the home until a permanent manager (subject to registration) is employed. 4 That in addition to the manager there is a minimum of one first level nurse and four care staff are on duty throughout the waking day (14hrs). 5 That at night there is a minimum of one first level nurse and two care staff on duty each night. 6 Ancillary staff are to be employed in addition to the minimum staffing levels to cover catering, laundry and cleaning. 7 That suited locks are to be fitted to all bedroom door within 12 months of registrationThat an existing bathroom on the first floor is converted to an assisted bathing facility within 12 months of registration. 9 That additional aids and adaptations are provided in the first floor shower room within six months of registration. 10 That the emergency call system is extended to cover all areas of the home within three months of registration. 11 That adequate heating is provided in the conservatory within 3 months of registration, and adequate air conditioning is provided in the same room within 6 months of registration.. Date of last inspection First Inspection Abbeyrose Nursing Home E54_S61145_Abbeyrose NH_V220142_190505 Stage 4.doc Version 1.30 Page 5 Brief Description of the Service: Abbeyrose is a three storey detached property situated in a quiet residential area in Erdington. It is approximately half a mile from the main shopping area and is within close proximity of public transport. There is limited parking to the front of the property with a pleasant enclosed garden to the rear. The ground floor and first floor provide accommodation for twenty five residents over 65 years of age who require nursing care. The third floor of the property is designed for staff use only and the new proprietors are in the process of developing the staff facilities. The home has seventeen single rooms and four double rooms. All rooms have a wash hand basin and two of the single rooms have en-suite facilities. The new proprietors have produced plans to provide en-suite facilities to another two bedrooms. Double rooms are provided with privacy curtains. There are four bathing facilities divided between the two floors, one of which has recently been converted into an assisted shower facility enabling it to be used by residents. The kitchen is situated on the ground floor and the laundry is separate to the main building in the rear of the garden. There is one combined lounge dining room to the front of the property with a pleasant conservatory to the rear, which looks out on to the garden. Since the new proprietors took over they have developed another sitting area that is used as a reception or quiet room and they have undertaken a considerable amount of re-decoration and refurbishment that is ongoing. Abbeyrose Nursing Home E54_S61145_Abbeyrose NH_V220142_190505 Stage 4.doc Version 1.30 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was conducted on an announced basis over two days commencing at 8.30 on 19th May 2005. The manager, administration manager and facilities manager were present and the proprietor visited during the first day of the inspection. During the inspection process the inspector toured the home, sampled residents files and other documentation. The manager, three members of staff, approximately six residents and three relatives who were visiting were spoken to. Written feedback was also received from four relatives and two health and social care personnel. At the time of inspection a number of residents in the home were unable to verbally communicate. Of the residents spoken to their views were positive stating that staff treated them well. This is the first inspection with the proprietor and it was noted that considerable improvements had been made in the home. What the service does well: What has improved since the last inspection? Abbeyrose Nursing Home E54_S61145_Abbeyrose NH_V220142_190505 Stage 4.doc Version 1.30 Page 7 There have been significant improvements in the décor and cleanliness of the home, providing a relaxed and homely atmosphere. There has also been an improvement in the standard of laundry and the arrangements for the storage of resident’s clothes There is a more stable staff group with a nurse manager who has been in post since the new proprietors took over, which has lead to some improvements. Feedback from health and social care professionals was positive indicating that the home was improving. The manager has implemented good systems for the management of medication and it was found to be of a good standard. An administration manager, who has developed comprehensive information for prospective residents and their families, supports the nurse manager. Currently he is in the process of developing the statement of purpose, terms and conditions of residence and other records required by the regulations. The facilities manager is responsible for all equipment plus maintenance etc. Lockable facilities have been provided in bedrooms and locks have been purchased for bedroom doors, which are to be fitted in the near future. A range of equipment has been serviced and he is in the process of reviewing all equipment. 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. Abbeyrose Nursing Home E54_S61145_Abbeyrose NH_V220142_190505 Stage 4.doc Version 1.30 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Abbeyrose Nursing Home E54_S61145_Abbeyrose NH_V220142_190505 Stage 4.doc Version 1.30 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4,5, The home provides comprehensive information to enable prospective residents to make a decision about entering the home. Assessments fail to provide sufficient information to staff in order to facilitate them in meeting all care requirements. EVIDENCE: The home provides long term care for residents over 65 years of age. They have recently drawn up a statement of purpose and service user guide and at the time of inspection copies were available. The service user guide was fairly comprehensive, but the statement of purpose requires enhancing, as it was not detailed and some of the areas listed in the Regulations had not been included. The home is in the process of developing the terms and conditions of residency. The document will need to include the room number and then copies will need to be distributed to all residents or their representatives. At the time of inspection some relatives were spoken to and they stated that the home gave them a considerable amount of information before their mother moved in and made them welcome on visiting. They confirmed that an assessment had been undertaken by the home prior to admission and they were happy with the care received by their mother. They found the staff were very friendly, most helpful and stated “They see to things straight away”. Abbeyrose Nursing Home E54_S61145_Abbeyrose NH_V220142_190505 Stage 4.doc Version 1.30 Page 10 The home liaises with social workers who provide written assessments/care plans for residents who wish to enter the home. The home invites prospective residents to visit or they undertake an assessment in their own home or hospital. Following admission to the home there is a full assessment is completed enabling a care plan to be drawn up. On inspection of the assessment records it was found that the pre-admission assessment was completed, but the assessment form on admission to the home had not been fully completed. Risk assessments had been completed including moving and handling, skin falls etc. The home writes to prospective residents confirming if they are able to meet their needs. The proprietors and manager only took control of the home approximately five months ago and this is an area that will need to be developed. Consideration will need to be given to obtaining information from family members and any other significant individuals when drawing up an assessment. Some staff have undertaken training in caring for residents with dementia as the home has a number of residents with dementia. Consideration will also need to be given to training in mental health illness particularly in relation to some residents who are currently residing in the home. Abbeyrose Nursing Home E54_S61145_Abbeyrose NH_V220142_190505 Stage 4.doc Version 1.30 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10 Written and verbal feedback indicated that the home had made significant improvements. However, shortfalls in the recording system cannot guarantee consistency. Clear comprehensive arrangements had been installed to ensure service users medication needs are met. EVIDENCE: The home draws up a care plan for all residents on admission to the home. A small sample were inspected and they were found to cover a number of areas, but some aspects lacked detail, some needs had not been included in the plan of care and there was no evidence that the resident or their family had been involved with the process. In one case fluid charts were noted indicating that the home was monitoring a residents fluid intake, but this information had not been included in the plan of care. Where a resident needed the hoist for moving there was no indication of the type of hoist or size of sling and there were no details about the care of a PEG tube and arrangements for administering medication for one resident. The care plans had been reviewed on a monthly basis, but the plan of care had not been updated where there were changes in care. In some instances the records had not been signed or dated. In order for a consistent approach to care detailed care plans should be in place for all staff to access otherwise they are reliant on good verbal communication and memory. Abbeyrose Nursing Home E54_S61145_Abbeyrose NH_V220142_190505 Stage 4.doc Version 1.30 Page 12 The home monitors resident’s nutritional status through regular weighing and nutritional screening. On discussion with a visitor she stated, “we never thought she would walk, but now she is walking and has put on weight. Mum calls it home”. Staff liaise with health professionals from the multidisciplinary team such as social workers, CPN’s, tissue viability nurse. Feedback from health professionals indicated that there is always a senior member of staff available and they have a clear understanding of residents needs. The home has a range of pressure relieving equipment in use and there are no residents with any pressure sores at present. The facilities manager is currently reviewing all bed safety rails to ensure the correct ones are in place. On examination of records it was noted that the home record visits from health care professionals separately to enable easier retrieval of information and there was evidence of visits from the chiropodist and optician, but the inspector could not determine evidence of visits by the dentist. The pharmacist inspector found the medicine management was of a good standard. The majority of audits undertaken were correct. Systems had been installed and implemented to check the medicines received into the home. The new medication room was too hot at the time of the inspection and oxygen was not chained to the wall. The home had a homely remedy policy in place but it lacked important information for nursing staff to administer against. There was no evidence of written consent for vaccinations such as flu on one residents file and this will need to be addressed. At the time of inspection resident’s privacy and dignity was respected. Feedback from health professionals indicated that they were always able to meet with residents in private. Lockable facilities are available in rooms for residents to use for valuables or medication and they have purchased locks for bedroom doors, which are to be fitted in the near future. Curtains are fitted in shared rooms to ensure privacy is not compromised when personal care is given. A pay phone is available on the ground floor and a hands free set is available for use if privacy is required. Abbeyrose Nursing Home E54_S61145_Abbeyrose NH_V220142_190505 Stage 4.doc Version 1.30 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,15 Dietary needs of residents were catered for with a varied selection of meals available. There has been some progress in respect of social activities and the managers acknowledged that further development of this area is required. EVIDENCE: The new proprietors and manager took over the home approximately five months ago and are aware that social activities is an area that needs to be developed. They do have an activities co-ordinator visiting on a weekly basis and since they have taken over they have an entertainer who visits the home monthly, there are sessions of exercise to music, sing along/dancing and they have purchased some fishing rods for some residents who enjoy fishing. One of the residents visits a day centre twice a week. There is a large screen television, video recorder and music system in the main lounge. The hairdresser visits regularly and religious ministers of various denominations visit as requested. On discussion with visitors they stated they could visit at any time, were always made welcome and offered a drink. There is a choice of areas to sit and the home has a new reception room that has been decorated and furnished to a good standard. It was stated by relatives that they were allowed to do as they wanted to their mother’s room and there was always a member of staff around. One relative stated the home offered to make a birthday cake and facilitated a family party in the conservatory. Abbeyrose Nursing Home E54_S61145_Abbeyrose NH_V220142_190505 Stage 4.doc Version 1.30 Page 14 The home employs separate catering staff who provide three full meals per day, which includes a cooked breakfast three days per week. There is a fourweek menu with a choice of meals at lunchtime. The evening meal consists of soup and sandwiches and it was stated that they are hoping to develop it in order to provide a cooked option. Snacks and drinks are available between meals and it was noted that residents had biscuits or sandwiches mid-morning. Residents are consulted about choices approximately three days in advance and it is confirmed on the day of serving. A record of lunch choices were available and the inspector was informed that records of other meals taken by residents was also kept by the home. The inspector had lunch with residents and found the meal to be hot and tasty. The meal was unhurried; staff were available and gave assistance to residents as required. Abbeyrose Nursing Home E54_S61145_Abbeyrose NH_V220142_190505 Stage 4.doc Version 1.30 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,18 Feedback indicated that the home is responsive to concerns raised. The procedures in place fail to fully address concerns raised and, therefore, may not fully protect residents. EVIDENCE: The home has a complaint procedure available in the entrance hall and in the service user guide. On inspection it was noted that it needs to be amended to inform residents and their representatives of their right to contact the Commission at any stage with a complaint if they wish. The home has had one complaint, which was forwarded to the Commission since the new proprietors took over. It has been investigated by the home and letters forwarded to the Commission and the complainants. A copy of the complaint was retained in the home. The manager has been advised the both formal and informal complaints should be recorded indicating outcome and resolution. At the time of inspection the home had a procedure to follow in the event of any allegation of abuse. They were advised that they need to obtain a copy of the Local Authority guidance document and ensure the homes procedure complies with it. On discussion with some staff they were aware of the procedures and there had been some training in the home recently. However, some staff responses lacked clarity and this area will need to be followed up to ensure all staff are fully aware of procedures. Abbeyrose Nursing Home E54_S61145_Abbeyrose NH_V220142_190505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,23,24,25,26 The new proprietors have made a number of improvements in the home, which is improving week on week. There is a range of communal areas to sit and it provides a relaxing homely environment. EVIDENCE: The home is a detached converted three-storey building that is set in it own grounds. There is limited parking to the front of the property and a pleasant garden to the rear of the building. At the time of inspection the home was clean and odour free. The new proprietors are in the process of re-decorating and refurbishing the home. One of the visitors stated that week-by-week they are improving the home. Abbeyrose Nursing Home E54_S61145_Abbeyrose NH_V220142_190505 Stage 4.doc Version 1.30 Page 17 There is one lounge/dining room on the ground floor to the front of the property that has been re-decorated and new carpets have been fitted. There is now a new reception room/quiet room, which is very nicely decorated and furnished plus a conservatory to the rear of the property, which looks out onto the garden. The new proprietors have purchased additional air conditioning units for the summer period and have plans to provide suitable screening to the roof of the conservatory to prevent glare from the sun. The garden is well maintained with new furniture to use on the patio when weather permits. It was noted that the cover to the cellar was not secure. This will need to be addressed in the near future especially as the weather improves. There is a combination of double and single rooms, which are furnished and personalised by some residents and their families. Two of the rooms have ensuite facilities and double rooms have privacy curtains fitted. There are plans to provide en-suite facilities in a further two bedrooms. During inspection it was noted that lockable facilities have been provided in rooms and some have been re-decorated. A wardrobe was found to be a little unstable in one room. An audit of all furniture should be undertaken and appropriate action taken to repair or replace any items that are not suitable. The home has purchased locks and they are to be fitted to bedroom doors within the near future. All rooms are individually and naturally ventilated and windows are provided with restrainers. Radiators are of the low surface temperature type and water from hot water outlets is regulated. There are assisted bathing facilities on each floor and the new proprietor has recently upgraded one bathroom to provide an assisted shower facility. Laundry facilities are situated to the rear of the property. It is fitted with two washing machines and dryers and separate staff take responsibility for laundering of linen and residents clothing. The area was orderly and tidy. The home has a separate sluice on the first floor and during inspection it was noted that the area required more thorough cleaning and there were no hand towels for staff use. The kitchen is on the ground floor and the proprietors have plans to develop the kitchen facilities in the near future. A report was available from the environmental health officer and some areas are still to be addressed. Abbeyrose Nursing Home E54_S61145_Abbeyrose NH_V220142_190505 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29 There have been improvements in the recruitment procedures with a more stable staff group. Training is ongoing with the development of staff skills in the home. EVIDENCE: The staffing rotas indicated there is one nurse and four care staff on duty between 8am and 8pm with one member of staff remaining on duty until 9pm. There is one nurse and two care staff on duty overnight. In addition, there is a manager, catering, and ancillary staff. The conditions of registration state there should be a nurse and four members of care staff on duty 14 hours per day. This has been discussed with the proprietor and manager and they have been advised to review staffing levels and forward a written proposal to the Commission. On inspection of staff files it was found that an application form, POVA check and CRB had been completed for all staff. References were available, but on one file it was noted that there was only one reference. It was stated that a verbal reference had been obtained. The home will need to ensure records are kept of verbal references to include the name and designation of the person providing the reference and followed up by a written reference. The home continues to recruit new staff and is using a small number of agency staff. This is an improvement since the last inspection and has lead to some improvements in the continuity of care. Abbeyrose Nursing Home E54_S61145_Abbeyrose NH_V220142_190505 Stage 4.doc Version 1.30 Page 19 The home has two staff who have completed NVQ training and one is currently undertaking the training. They are hoping to develop this further and the manager has started to develop of library, which staff can utilise for training purposes. Since the new proprietors have taken over the home there has been a range of training in respect of nutrition, basic food hygiene, medication management, dementia, health and safety, plus moving and handling. Written feedback to the Commission indicated that staff were enthusiastic and welcoming plus it was a home that was improving. Abbeyrose Nursing Home E54_S61145_Abbeyrose NH_V220142_190505 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,35,38 There has been a significant improvement in the management of the home with a clear vision for the future. Health, safety and welfare of residents needs to be further promoted and protected by ensuring that staff receive up to date health and safety and fire training. EVIDENCE: The manager is a registered nurse with several years experience. She has been in post for approximately five months and is currently undertaking the registered managers award. An application is to be made to the Commission for registration. On discussion with staff they stated the manager was approachable and helpful. They stated they got on well as a group, but felt there could be some improvements in communication. They confirmed that there had been one staff meeting since the new proprietors took over and another one was due. It was also stated that the home hopes to arrange meetings for residents and relatives enabling them to play a part in the home. Abbeyrose Nursing Home E54_S61145_Abbeyrose NH_V220142_190505 Stage 4.doc Version 1.30 Page 21 On discussion with the manager she stated that formal supervision had not been undertaken to date. The home has just employed a facilities manager, who will be responsible for overseeing maintenance, servicing etc. A sample of records was inspected in relation to maintenance and they were found to be of a generally satisfactory standard. Water temperatures were within safe limits, but he hopes to follow up this area to ensure greater consistency and constant temperatures. The fire points and emergency lighting had recently been checked and he was in the process of assessing the suitability of all bed safety rails. Areas that require addressing are staff training in respect of fire prevention and fire drills as some staff lacked clarity in respect of the procedures to follow in the event of a fire. Also risk assessments in respect of fire, and the environment need to be developed. The home has a range of policies and procedures, but on discussion with staff there was some lack of consistency in respect of some clinical procedures and this area will need to be followed up through the development of clinical procedures, communication of them to staff and supervision to ensure they are implemented. The proprietor visits the home regularly, but there was no evidence of any monthly reports at the time of inspection. These should be available in the home. It was stated the home does not hold any money or valuables on behalf of residents and invoices would be raised for any expenditure incurred if necessary. Abbeyrose Nursing Home E54_S61145_Abbeyrose NH_V220142_190505 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 2 2 2 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 2 3 3 x 3 2 3 2 STAFFING Standard No Score 27 3 28 2 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 2 2 2 x 3 1 x 2 Abbeyrose Nursing Home E54_S61145_Abbeyrose NH_V220142_190505 Stage 4.doc Version 1.30 Page 23 N/A Are there any outstanding requirements from the last inspection? 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 1 Regulation 5 Requirement The registered person must ensure the Statement of Purpose is enhnaced to provide more detailed information and cover all areas outlined in the regulations. The terms and conditions of residence should include the room number. When completed all resdients or their representatives should receive a copy and a copy retained in the residents file in the home. The registered person must review the assessment process for residents entering the home ensuring that a comprehensive assessment is drawn up and includes the resident or any other significant stakeholders. The registered person must ensure staff receive training in repsect of caring for residents currently in the home with specific mental health disorders. The registered person must ensure all care plans outline in detail the action to be taken by staff to meet residents needs. They must include all needs; all areas must be signed and dated; Timescale for action 30/11/05 2. 2 5(1)(b) 30/8/05 3. 3 14 30/8/05 4. 4 18(1) 30/8/05 5. 7 15 30/8/05 Abbeyrose Nursing Home E54_S61145_Abbeyrose NH_V220142_190505 Stage 4.doc Version 1.30 Page 24 6. 8 13(1)(b) 7. 9 13(2) 8. 12 16(2)(m) (n) 9. 16 22 10. 18 13(6) 11. 19 16(2)(j) they must be updated where there is any change in care and demonstrate evidence of consultation with the resident or their representative. The registered person must ensure; All residents have opportunity to regular checks with the dentist and records are retained in the home. All residents requiring a wheelchair are referred for an assessment for a wheelchair to meet their needs. The registerd person must ensure the medication room temperature is monitored and if above 25°C an air conditioning system must be installed to ensure the medicines are stored within their product licences. The registered person must ensure an assessment is undertaken in respect of residents past interests/hobbies, a plan of activites drawn up and implemented and records retained in the home. The registered person must ensure the complaints procedure informs residents and their representative of their right to make a complaint the Commission at any stage. The registered person must obtain a copy of the Local Authority Vulnerable Adult Guidlines, ensure their procedures reflect them and all staff are made aware of the procedure to take in the event of any allegation of abuse. The registered person must ensure the issues from the envoronmental health officers report are addressed. 30/6/05 1 day and ongoing 309/05 30/6/05 30/7/05 30/8/05 Abbeyrose Nursing Home E54_S61145_Abbeyrose NH_V220142_190505 Stage 4.doc Version 1.30 Page 25 12. 24 13(4) 16(2)(c) 13(3) 13. 26 14. 15. 28 29 18(1) 19 16. 31 9 17. 18. 31 32 18(1) 9(2)(b)(i) 10(1) 12(1) 19. 36 18(2) 20. 33 10(1) 21. 33 26 The registered person must undertake an audit of all furnishings and replace or repair any damaged or unsfe items. The registered person must ensure the sluice area is cleaned and equipment for staff to wash their hands is availbel at all times. The registered person must ensure that at least 50 of staff are trained to NVQ level 2. The registered person must ensure; Verbal references are recorded and followed up with written references. Information is obtaiend from the agency regarding the employment checks undertaken for agency staff working in the home. The responsible person must forward an application for a registered manager to the Commission. The manger must complete the Registered Managers award The registered person must undertake a review of communication systems in the home with a view to addressing any shortfalls identified. The registered person must ensure formal supervision of staff is undertaken at least six times per year and records are retained in the home. The registered person must draw up clinical policies and procedures, ensure all staff are aware of them and they are implemented. The responsible person must produce a monthly report following his visits and a copy of the report must be retained in the home. 30/8/05 20/6/05 30/12/05 30/6/05 30/6/05 30/2/06 30/6/05 30/9/05 30/7/05 30/6/05 Abbeyrose Nursing Home E54_S61145_Abbeyrose NH_V220142_190505 Stage 4.doc Version 1.30 Page 26 22. 38 24(4)(d) (e) 23. 38 13(4) 24. 19 13(4) 25. 27 18(1) The registered person must ensure all staff undertake training in respect of fire prevention plus two fire drills per year and records must be retained in the home. The registered person must ensure risk assessmetns are undertaken in respect of fire and the envoronment. The registered person must ensure the cover to the cellar is made safe. Timescale of December 2004 not met. The registered person must undertake a review of staffing levels and forward a written proposal to the Commission . 30/7/05 30/8/05 30/6/05 30/6/05 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 9 Good Practice Recommendations The homely remedy policy should include drug indication, dose, warnings and cautions and be endorsed by a clinician. All quantities received and balances carried over from previous cycles should be routinely recorded to enable accurate audits to take place. Liquid medication and inhalers should be carried over and not returned to the pharmacy for destruction to reduce drug wastage. Oxygen must be securely stored at all times. Written consent should be obtianed for immunisations such as flu injections. . The home should retain records of informal compliants. 2. 16 Abbeyrose Nursing Home E54_S61145_Abbeyrose NH_V220142_190505 Stage 4.doc Version 1.30 Page 27 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Abbeyrose Nursing Home E54_S61145_Abbeyrose NH_V220142_190505 Stage 4.doc Version 1.30 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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