Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 22/11/05 for Abbeyrose Nursing Home

Also see our care home review for Abbeyrose Nursing Home for more information

This inspection was carried out on 22nd November 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

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

What the care home does well

The home has a friendly and relaxed atmosphere. Staff were welcoming and friendly. There are no rigid rules. Visiting is flexible and they are made welcome by staff and there are no rigid rules. The manager`s office is on the ground floor enabling easy access for residents or their relatives to discuss any issues. There are regular staff meetings and there was a good working relationship between staff. The home was warm, clean, odour free and generally well maintained providing a safe environment. The management team demonstrated knowledge and commitment and provide a strong group to oversee plans and developments for the home in the future.

What has improved since the last inspection?

There has been a range of staff training in the home including health and safety, fire prevention, infection control, communication etc. since the last inspection. The manager has commenced formal supervision meetings with staff and there had been an improvement in communication. The home is in the process of fitting locks to resident`s bedroom doors enabling them to lock the doors if they wish. A supply of fire stops had been purchased, which fit to bedroom doors enabling residents to have their bedroom doors open if they wish. Work is continued in respect of the social activities for residents.

What the care home could do better:

There needs to be a more robust recruitment procedure in the home to ensure all residents are adequately safeguarded. The re-decoration of the home needs to be completed to enhance the environment further. Development of the residents and relatives meetings as identified by the manager at the last meeting. Ongoing training in respect of NVQ level 2 plus basic food hygiene and first aid is required for staff to ensure they have the appropriate skills/knowledge.

CARE HOMES FOR OLDER PEOPLE Abbeyrose Nursing Home 38 Orchard Road Erdington Birmingham West Midlands B24 9JA Lead Inspector Ann Farrell Unannounced Inspection 22nd November 2005 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 Abbeyrose Nursing Home DS0000061145.V267258.R01.S.doc Version 5.0 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. Abbeyrose Nursing Home DS0000061145.V267258.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Abbeyrose Nursing Home Address 38 Orchard Road Erdington Birmingham West Midlands B24 9JA 0121 377 6707 0121 373 9667 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) MEB and Anand Concept Care Ltd Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Abbeyrose Nursing Home DS0000061145.V267258.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. That the Home is registered for nursing care for a maximum of 25 service users for reasons of old age (OP). That the home can continue to provide care for existing named service users for reasons of Physical Disability (PD) - 1 person and Mental Disorder (MD) - 2 people. 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. 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). That at night there is a minimum of one first level nurse and two care staff on duty each night. Ancillary staff are to be employed in addition to the minimum staffing levels to cover catering, laundry and cleaning. That suited locks are to be fitted to all bedroom door within 12 months of registration. That an existing bathroom on the first floor is converted to an assisted bathing facility within 12 months of registration. That additional aids and adaptations are provided in the first floor shower room within six months of registration. That the emergency call system is extended to cover all areas of the home within three months of registration. 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. 09/05/05 Date of last inspection Brief Description of the Service: Abbey rose 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 staff facilities are being developed. The home has seventeen single bedrooms and four double bedrooms. All Abbeyrose Nursing Home DS0000061145.V267258.R01.S.doc Version 5.0 Page 5 rooms have a wash hand basin and two of the single bedrooms have en-suite facilities. Double rooms are provided with privacy curtains. There are four bathing facilities divided between the two floors, which provide a choice of bathing facility. The kitchen is situated on the ground floor and the laundry is separate to the main building to 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. In addition, there is a small sitting room to the front of the building that is used as a reception or quiet room. The proprietors are currently in the process of extending the home to provide a further five bedrooms and it is hoped that they will be available in the near future. Abbeyrose Nursing Home DS0000061145.V267258.R01.S.doc Version 5.0 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out over one day on 22nd November 2005 commencing at 9am. This was the second statutory inspection for 2005/2006. This report should be read in conjunction with the report of the inspection conducted in May 2005 to obtain an overall view of the home. The manager, administration manager and facilities manager were present during the inspection. During the inspection process the inspector sampled some bedrooms and communal areas, some residents files and other documentation. The manager, three members of staff and approximately four residents were spoken to. At the time of inspection a number of residents in the home were unable to verbally communicate. What the service does well: What has improved since the last inspection? There has been a range of staff training in the home including health and safety, fire prevention, infection control, communication etc. since the last inspection. The manager has commenced formal supervision meetings with staff and there had been an improvement in communication. Abbeyrose Nursing Home DS0000061145.V267258.R01.S.doc Version 5.0 Page 7 The home is in the process of fitting locks to resident’s bedroom doors enabling them to lock the doors if they wish. A supply of fire stops had been purchased, which fit to bedroom doors enabling residents to have their bedroom doors open if they wish. Work is continued in respect of the social activities for residents. 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 DS0000061145.V267258.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection Abbeyrose Nursing Home DS0000061145.V267258.R01.S.doc Version 5.0 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 the following standard(s): 3, 4, 6 The home provides information to enable prospective residents to make a decision about entering the home. Assessments require further development to provide sufficient information to staff in order to facilitate them in meeting all residents’ needs. EVIDENCE: The home provides long term care for residents over 65 years of age. They have information available for prospective residents and their families enabling them to make an informed choice, but this was not viewed at the time of inspection. 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 of their needs in their own home or hospital. Following admission to the home 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 on admission to the home had not been fully Abbeyrose Nursing Home DS0000061145.V267258.R01.S.doc Version 5.0 Page 10 completed in all cases. Risk assessments had been completed including moving and handling, tissue viability, falls etc. 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 provide training in mental health illness particularly in relation to some residents who are currently residing in the home. Abbeyrose Nursing Home DS0000061145.V267258.R01.S.doc Version 5.0 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 the following standard(s): 7, 8, 9 The home has good arrangements in place to meet resident’s health care needs. The care plans need developing further to ensure all care needs are met. The medication system needs enhancing to ensure all residents receive medication prescribed to them. EVIDENCE: The home draws up a care plan for all residents on admission to the home, which outlines the action required by staff to meet resident’s needs. A small sample of care plans were inspected and it was noted that there had been some improvements. However, some areas still lacked detailed information as to the action required to meet residents’ needs and some areas of care had not been included in the plan of care. Resident’s nutritional status was monitored through regular weighing and nutritional screening, but there was no indication of an objective tool such as body mass index. It is recommended that the home commence using an objective tool when undertaking nutritional assessments. Staff liaise with health professionals from the multidisciplinary team such as social workers, CPN’s, tissue viability nurse etc and have a range of pressure Abbeyrose Nursing Home DS0000061145.V267258.R01.S.doc Version 5.0 Page 12 relieving equipment. On inspection of one residents record who had returned from hospital with a pressure sore it was noted that they a Sorbian dressing had been used, but this had not been continued by staff in the home. On discussion with the nurse she stated that they were waiting for a prescription from the G.P. It is recommended that this area be reviewed to determine if such prescriptions can be obtained quicker or hospitals can provide an appropriate supply of dressings to use whilst the home is waiting for a prescription to be dispensed. Since the last inspection the facilities manager has undertaken a review of bed rails and other equipment in the home ensuring that appropriate equipment is in use. 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, dentist and optician. On inspection of medication and it was found to be satisfactory in the monitored dosage system. Some discrepancies were noted in the boxed medication. Suitable systems are in place to check the medicines received into the home, but the medication room was too hot for the storage of medication and this will need to be addressed. It is recommended that the manager undertake some staff audits in respect of the medication. At the time of inspection resident’s privacy and dignity was respected. Lockable facilities are available in bedrooms enabling residents to use them for valuables or medication. Suitable locks are currently being fitted to resident’s bedroom doors enabling them to lock the door if they wish. 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 telephone is available for use if privacy is required. Abbeyrose Nursing Home DS0000061145.V267258.R01.S.doc Version 5.0 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 the following standard(s): 12, 14 Visiting is flexible and there are no rigid rules. Progress continues to be made in respect of social activities. EVIDENCE: There are no strict rules in the home and residents are free to come and go as they wish, depending on their capability. Visiting is flexible. Residents are able to make choices about getting up, going to be and where to take their meals. Staff have commenced collecting information in respect of residents interests and hobbies. This will need to be developed further to provide more detail about ranges of activities. Staff are allocated to provide assistance and support to residents in respect of activities. Areas currently included are games, drawing, crafts, music and a barbeque was held in August. They have purchased some fishing rods for some residents who enjoy fishing and 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. Abbeyrose Nursing Home DS0000061145.V267258.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Procedures are in place for the protection of residents, but further training is required to ensure they are fully protected. EVIDENCE: The home has a complaint procedure, which is available on the notice board in the entrance hall, which was satisfactory. On discussion it was stated that the home had received one complaint since the time of the last inspection. However, records were not available for inspection. The manager must ensure the record of complaints is retained in the home for inspection indicating the nature of the complaint, the investigation, outcome and resolution. Since the time of the last inspection the manger has obtained a copy of the Local Authority vulnerable adult guidance document. The manger stated that staff had received training in this area. On discussion with staff some were fully aware of the procedures including the whistle blowing policy, but there was still some staff who lacked clarity about the procedure. An incident involving two residents had occurred in the home had it had not been reported to the social worker. The manager will need to ensure that this area is followed up and if there are any further incidents the social worker is informed. Abbeyrose Nursing Home DS0000061145.V267258.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 The home was clean and warm with a relaxing atmosphere. The re-decoration to date has provided pleasant surroundings for residents. Further redecoration is required to complete the process. EVIDENCE: The home is generally well maintained. At the time of inspection it was warm, clean and odour free. There is one lounge/dining room on the ground floor to the front of the property, which has been re-decorated and furnished providing a pleasant area to sit for residents. In addition, there is a 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 garden is well maintained with new furniture to use on the patio when weather permits. Abbeyrose Nursing Home DS0000061145.V267258.R01.S.doc Version 5.0 Page 16 There is a combination of double and single bedrooms, which are furnished and personalised by some residents and their families. Two of the rooms have ensuite facilities, double rooms have privacy curtains and staff are in the process of fitting locks to bedrooms doors to enable residents to lock them if they wish. 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 with a choice of bath or 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. On discussion with the member of staff there appeared to be some lack of clarity around the use of alginate bags and the manager stated she would follow this area up. Abbeyrose Nursing Home DS0000061145.V267258.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29, 30 Satisfactory staffing levels were being maintained to meet residents needs and training is on going. The recruitment procedure is poor and does not adequately protect residents. EVIDENCE: The staffing rotas indicated there is at least one nurse and five care staff on duty during the morning, one nurse and four care staff during the evening and one nurse and two care staff on duty overnight. In addition, there is a manager, catering, and ancillary staff. Although this appears adequate to meet the needs of residents currently it is not in line with the conditions of registration, which state one nurse and four members of care staff should be on duty 14 hours per day. This area will be addressed at the time of registering the extension to the home. On inspection of staff files they were found to be unsatisfactory, as a number of files did not have current POVA or CRB check, some did not have proof of identity or current work permit/visa. In one instance a file could not be located for one new member of staff. An immediate requirement was left with the manager for this area to be addressed with some urgency. Induction training is undertaken with newly appointed staff. Abbeyrose Nursing Home DS0000061145.V267258.R01.S.doc Version 5.0 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 38 The manager provides an open, positive approach and there have been improvements in communication and the implementation of formal staff supervision since the last inspection. The health, safety and welfare of residents is protected. EVIDENCE: The manager is a registered nurse with several years experience. She has forwarded an application form to the Commission for registration and has just been successful at the fit person interview. On discussion with staff they stated the manager was approachable, helpful and she demonstrated a professional approach. They stated they got on well as a group and felt they worked well as a team. They confirmed that regular staff meetings were held and records indicated that formal supervision sessions had commenced. On inspection it was found that one meeting had taken place to date, but records need more detail about the areas discussed. Abbeyrose Nursing Home DS0000061145.V267258.R01.S.doc Version 5.0 Page 19 At the last inspection it was stated that the staff hope to arrange meetings for residents and relatives enabling them to play a part in the home, but this area was not followed up. The home has employed a facilities manager, who is responsible for overseeing maintenance, servicing etc and is currently involved with the extension to the home. Areas outstanding at the last inspection were followed up and found to be satisfactory. The proprietor visits the home regularly, but there was no evidence of any monthly reports as required under the regulations. It was stated that a quality assurance system has not been introduced to the home yet. The proprietor has purchased a number of fire stops to use on bedroom doors, but it was noted that some other doors were propped open with wedges etc. This practice must not continue as it may put residents at risk. Since the last inspection there has been training in respect of fire prevention, health and safety, infection control plus in house training in respect of communication, confidentiality, the statement of purpose etc. Abbeyrose Nursing Home DS0000061145.V267258.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 3 3 X X X X 2 STAFFING Standard No Score 27 3 28 X 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 1 X X 2 X 2 Abbeyrose Nursing Home DS0000061145.V267258.R01.S.doc Version 5.0 Page 21 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 5 Requirement The registered person must ensure the Statement of Purpose is enhanced to provide more detailed information and cover all areas outlined in the regulations. This requirement was not assessed and has been carried forward from 30/11/05. The terms and conditions of residence should include the room number. When completed all residents or their representatives should receive a copy and a copy retained in the residents file in the home. This requirement was not assessed and has been carried forward from 30/8/05. The registered person must ensure assessments are fully completed for all residents following admission to the home. Timescale of 30/8/05 not met. Timescale for action 30/03/06 2. OP2 5(1)(b) 30/01/06 3. OP3 14 30/01/06 Abbeyrose Nursing Home DS0000061145.V267258.R01.S.doc Version 5.0 Page 22 4. OP4 18(1) 5. OP7 15 6 OP8 14 7. OP8 13(1)(b) 8. OP9 13(2) The registered person must ensure staff receive training in respect of caring for residents currently in the home with specific mental health disorders. This requirement was not assessed and has been carried forward from 30/8/05. The registered person must ensure all care plans outline in detail the action to be taken by staff to meet all resident’s needs. Timescale of 30/8/05 not met. The registered person must ensure an objective tool such as BMI is used when undertaking nutritional screening. The registered person must ensure all residents requiring a wheelchair are referred for an assessment to meet their needs. This requirement was not assessed and has been carried forward from 30/6/05. The registered 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. 30/03/06 30/01/06 30/12/05 30/03/06 30/12/05 9. OP16 22 10. OP18 13(6) The registered person must ensure the correct administration of all prescribed medication. The registered person must 30/12/05 ensure a record of all complaints is retained in the home and it must be available for inspection. The registered person must 30/01/06 ensure all staff are fully conversant with the vulnerable adult and whistle blowing policies. Abbeyrose Nursing Home DS0000061145.V267258.R01.S.doc Version 5.0 Page 23 11. OP26 13(3) 12. 13. OP28 OP29 18(1) 19 The registered person must ensure staff are fully conversant with the use of alginate bags in line with infection control procedures. The registered person must ensure that at least 50 of staff are trained to NVQ level 2. The registered person must ensure a robust recruitment procedure to include POVA and CRB checks, two written references, proof of identity, work permit and visa. The home has received an immediate requirement in respect of this area. The manger must complete the Registered Managers award. The registered person must ensure records of formal supervision are expanded to include all areas discussed at the time of meeting. The registered person must draw up clinical policies and procedures, ensure all staff are aware of them and they are implemented. This requirement was not assessed and has been carried forward from 30/7/05. The responsible person must produce a monthly report following his visits to the home and a copy of the report must be retained in the home. Timescale of 30/6/05 not met. The registered person must introduce a quality assurance system into the home seeking feedback from stakeholders and draw up a plan outlining outcomes for residents. 20/12/05 30/03/06 22/12/05 14. 15. OP31 OP36 18(1) 9(2)(b)(i) 18(2) 30/10/06 30/12/05 16. OP33 10(1) 30/03/06 17. OP33 26 30/12/05 18. OP33 24(1)(3) 30/05/06 Abbeyrose Nursing Home DS0000061145.V267258.R01.S.doc Version 5.0 Page 24 19. OP38 13(4) 20 OP38 18(1) The registered person must ensure risk assessments are undertaken in respect of fire and the environment. Timescale of 30/8/05 not met. The registered person must ensure staff undertake training in respect of basic food hygiene and first aid. The registered person must ensure that all fire doors are kept closed unless they are kept open with a suitable devise that enables the door to close in the event of the fire alarm being activated. 30/03/06 30/03/06 21. OP38 23(4) 20/12/05 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 OP8 Good Practice Recommendations It is recommended that the manager review the system of obtaining prescriptions for dressings for residents returning from the hospital to ensure there is no interruption in the dressing programme. When staff are undertaking assessments of residents interests and hobbies more specific information should be obtained to enable an appropriate plan of activities to be drawn up. 2 OP12 Abbeyrose Nursing Home DS0000061145.V267258.R01.S.doc Version 5.0 Page 25 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 DS0000061145.V267258.R01.S.doc Version 5.0 Page 26 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!