Inspection on 29/08/06 for Abbeyrose Nursing Home

This inspection was carried out on 29th August 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

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 22/11/05

Abbeyrose Nursing Home 19/05/05

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 West Midlands B24 9JA Lead Inspector Ann Farrell Unannounced Inspection 29th August 2006 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.V309685.R02.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. Abbeyrose Nursing Home DS0000061145.V309685.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbeyrose Nursing Home Address 38 Orchard Road Erdington Birmingham West Midlands B24 9JA 0121 377 6707 0121 240 6181 enquiries@abbeyrose.org.uk 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) MACC Care Limited Mrs Olubamike Aduke Adeyemi Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places Abbeyrose Nursing Home DS0000061145.V309685.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. That the Home is registered for nursing care for a maximum of 30 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. 22nd November 2005 Date of last inspection 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 thirty residents over 65 years of age who require nursing care. The third floor of the property is designed for staff use only. The home has twenty-two single bedrooms and four double bedrooms. All rooms have a wash hand basin and seven 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. There is a range of equipment for moving and handling residents plus raised toiler seat and handrails. A passenger lift is available that gives access to all areas in the home. The kitchen is situated on the ground floor and the laundry is separate to the main building at 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 two further small sitting rooms providing a choice of areas to sit. Abbeyrose Nursing Home DS0000061145.V309685.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The fieldwork inspection was conducted over two days commencing at 8.00 am on 29th August 2006. This was the first statutory inspection for 2005/2006. The acting manager was available for the inspection. During the inspection process the inspector toured the home, sampled residents files and other documentation. Case tracking was used in respect of a small number of resident’s files to determine care from the time of admission to the home plus direct and indirect observation A pre-inspection questionnaire with comment cards were forwarded to the home prior to the fieldwork in order to obtain feedback and assist with the process. The document was returned, but no comment cards were received. During the fieldwork the acting manager, five members of staff, eight residents and three relatives were spoken to on the day. A considerable number of residents were unable to communicate verbally and their views could not be obtained. What the service does well: What has improved since the last inspection? The call bell system had been up graded and can be moved to where ever residents sit enabling them to summon assistance at any time. There has been some new equipment e.g. hoists, fridge and carpets in bedrooms. Staff have been provided with uniforms and name badges providing a professional approach. Abbeyrose Nursing Home DS0000061145.V309685.R02.S.doc Version 5.2 Page 6 There has been a new extension to the home with a further five en-suite bedrooms plus an additional sitting room and toilet facility. 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.V309685.R02.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 Abbeyrose Nursing Home DS0000061145.V309685.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 6 Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to this service. The home provides information for prospective residents regarding the services available, but it requires updating. Assessments require further development with involvement of the resident or their representative 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 has not been updated since the extension to the home. These documents will need developing to ensure the prospective residents have information to enable them to make an informed choice. The home should consider alternative formats such as large print when reviewing the service user guide. Since previous inspections a contract has been developed and is used for privately funded residents. A contract or terms and conditions will need to be Abbeyrose Nursing Home DS0000061145.V309685.R02.S.doc Version 5.2 Page 9 provided to residents funded by Social Care and Health also to ensure they are aware of the terms of residency. The acting manager undertakes a pre-admission assessment for all residents wishing to move into the home. Prospective residents are also able to visit the home enabling them to view facilities and make a decision about moving in. . Following admission to the home an admission document and risk assessments are undertaken. 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 and residents or their representatives had not been involved in the process. On discussion with some relatives it was apparent that they had further information that was relevant to residents care. Risk assessments had been completed including moving and handling, skin, falls, nutrition, and skin integrity in the majority of cases. It was noted that the handling assessment did not indicate the action to be taken if a resident sustains a fall. The admission process will need to be reviewed in order that residents or their representative is involved in the process and a comprehensive assessment is completed. Some staff have undertaken training in caring for residents with dementia as the home has a number of residents with confusion/dementia. This will need to be extended to the remaining staff to ensure all staff have the appropriate knowledge and skills to care for residents with dementia. Abbeyrose Nursing Home DS0000061145.V309685.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to this service. The home has satisfactory arrangements in place to meet resident’s health care needs. The care plans and communication of them to care staff needs to be developed further to ensure all care needs are met in a consistent manner. The medication system needs reviewing and developing, as it could not be guaranteed that residents receive medication prescribed to them. EVIDENCE: Staff develop a care plan for all residents on admission to the home outlining how residents needs are to be met. Small samples were inspected and it was found that they contained a significant amount of information. However, in some cases the instructions were vague or generalised and did not give specific information as to how needs were to be met and some aspects had had been omitted. The care plan for one resident with a PEG feed tube did not indicate the care of the tube or details about the administration of medication. On discussion with care staff they stated they were not aware of residents care plan and there was some confusion over the number of residents who were being barrier nursed. Abbeyrose Nursing Home DS0000061145.V309685.R02.S.doc Version 5.2 Page 11 The daily recording was very generalised and did not reflect changes in resident’s conditions. Fluid balance charts were not fully completed or calculated at the end of a 24-hour period suggesting that this aspect was not being monitored. The charts used to record that residents were being turned on a regular basis indicated that all residents were turned at exactly the same time, which is impossible. The accuracy of the recording of food charts was brought into question as some indicated that residents whose condition was deteriorating were eating a full diet. Resident’s nutritional status was monitored through regular weighing and nutritional screening and the staff are now using the BMI, which is an objective tool to determine if the resident is under weight. It was noted that a small number of residents were under weight and it was stated they had been referred to the dietician. 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 relieving equipment. It was noted that some residents were considered to be at a high risk following a tissue viability risk assessment, but there was no indication that appropriate action had been taken to address this. Also it was noted that some of the pressure relieving cushions were damaged and will need replacing. It is recommended that the acting manger liaise with the tissue viability nurse regarding this aspect. There was evidence of regular visits from the chiropodist, dentist and optician. During inspection it was noted that the management of urinary catheter bags was poor and the care plans lacked detail about the care. Also one resident who required bed rails had moved rooms and there were no rails on the new bed. This would put the resident at risk of falling out of bed as they had been assessed as requiring this equipment. These areas were discussed with the acting manger. A new hoist has been purchased, but there appeared to be a lack of sliding sheets for moving residents in bed as they should have one each to reduce the risk of cross infection. The acting manager will need to undertaken a review of manual handling equipment and ensure there is adequate equipment in the home. One resident had been assessed for a suitable chair some time ago, but it had not been delivered. The acting manager was asked to follow this area up. Staff were monitoring one residents diabetes by undertaking blood sugar monitoring once a week. The latest guidelines indicate that blood sugar monitoring should be undertaken if residents are ill or there is a change in their condition and diabetes is monitored through blood tests undertaken by health professionals. The acting manager should liaise with the G.P. about this Abbeyrose Nursing Home DS0000061145.V309685.R02.S.doc Version 5.2 Page 12 aspect and it is recommended that some training be sought to update staff in respect of diabetes. On inspection of medication it was found that a number of areas need to be addressed in order to ensure a robust system. The following areas were not satisfactory: • A number of audits were not accurate. • Handwritten medication details had not been countersigned by two staff and were not accurate when checked with a hospital discharge letter. • There was no system for checking residents medication details when admitted from home or another residential establishment. • The doses of an antibiotic were not spread out over the 24 hours. • Prednisolone was recorded on the MAR chart as three tablets twice a day, but a nurse stated they had given six in one dose and the records did not demonstrate this. • Nutritional supplements had not been given as nurses had decided it was not required and this is not appropriate if they have been prescribed on a regular basis. • One resident was self administering his own medication, but a risk assessment had not been completed, there was no monitoring system in place and staff were signing to indicate that they had given the medication. • The administration of variable dose medication had not been recorded consistently. • Creams were in use that had not been prescribed and they were not dated when opened. • In some cases there was no clear records of medication entering the home to enable auditing to take place. • Two staff did not countersign the receipt of controlled drugs. • Destroyed medication was not stored in a locked cupboard. • The fridge and room temperature remained above that recommended for the storage of medication. • Oxygen cylinders were not secured appropriately and a statutory warning notice is required. Abbeyrose Nursing Home DS0000061145.V309685.R02.S.doc Version 5.2 Page 13 At the time of inspection resident’s privacy was respected and residents were well presented. Lockable facilities are available in rooms for residents to use for valuables or medication and locks have been fitted to bedroom doors enabling residents to lock them if they wish. Curtains are fitted in shared rooms to ensure privacy is not compromised when personal care is given. On discussion with residents and relatives they stated they were satisfied and the staff were good. One relative stated, “The staff are kind and loving.” Residents stated staff responded to requests for help, but in the evening there was a delay. 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 DS0000061145.V309685.R02.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to this service. Visiting is flexible, but there are fairly rigid routines in the home and they do not take individual choices into account. There has been little progress in respect of activities and this needs to be addressed in order to provide residents with adequate stimulation. The arrangements for meals and menus need to be reviewed to provide a greater choice at breakfast and evening meals plus some cultural options. EVIDENCE: Visiting is flexible and this was confirmed on the day of inspection through discussion with relatives and observation. Relatives stated they were welcomed to the home and were offered a drink. On discussion with one relative they were not aware of the arrangements for being kept updated regarding their relatives condition. It is recommended that this area be reviewed. Residents are able to make choices about meals, but there is limited choice in respect of the time for getting up and going to bed. On the first day of inspection it was noted that approximately ten residents were in the lounge at 8am and there were only six residents remaining up in the evening at 6.55 pm. Abbeyrose Nursing Home DS0000061145.V309685.R02.S.doc Version 5.2 Page 15 On discussion with some residents they stated they did not like getting up and going to bed so early. One stated, “We fell in with what they do.” This is not appropriate and action must be taken to determine resident’s wishes and choices and arrangements put in place to ensure they are met. Arrangements are made for a visiting entertainer and fashion show, but there was little evidence of any other activities. It was stated that range of games were available plus there is a television and music centre. However, due to the positioning of the chairs in the main lounge a number of residents cannot see the television. One of the residents visits a day centre twice a week. Staff had recorded some details about residents interests, but there was no evidence that this information was being used to occupy or stimulate residents. On discussion with some residents they stated they were bored. This area will need to be developed further in order to stimulate residents. The hairdresser visits regularly and religious ministers of various denominations visit as requested. There is a four-week rotating menu that is based on European foods with fresh fruit and vegetables, but there was little evidence of other cultural options. On discussion with residents they stated they enjoyed the meals, but some stated breakfast and evening meals were a little monotonous. There is a range of cereals for breakfast with a cooked option at weekends, but it is soup and sandwiches each evening. This will need to be reviewed with the option of a hot light meal in the evening. Abbeyrose Nursing Home DS0000061145.V309685.R02.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is poor. The judgement has been made using available evidence including a visit to this service. The procedures in place for adult protection failed to provide assurance that all allegations would be addressed appropriately. EVIDENCE: The homes complaint procedure was satisfactory and there was a record of three formal complaints since the last inspection. The record was complete for two of the complaints, but had not been completed for the third. Also there was no record of informal complaints/concerns. Records of complaints should be comprehensive with nature of complaint, investigation, outcome and resolution to demonstrate that complaints have been handled appropriately. On inspection of the adult protection and whistle blowing policy it was found to he in need of up dating to provide staff with the appropriate details of the action to take in the event of any allegation. Also there was some lack of clarity in staff knowledge on discussion with them and this will need addressing through training. Abbeyrose Nursing Home DS0000061145.V309685.R02.S.doc Version 5.2 Page 17 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, 20, 21, 23, 24, 25, 26 Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to this service. The home was warm with a pleasant atmosphere. The new extension has been decorated and furnished to a very good standard. Some of the original décor and furnishings need replacing. EVIDENCE: The home is generally well maintained. At the time of inspection the home was warm, there was a slight odour on entering and the level of cleanliness was not satisfactory in respect of the deep cleaning. Recently there has been an extension to the home providing five single ensuite rooms and small lounge area, which were decorated and furnished to a very good standard. In the original part of the building there is one lounge/dining room on the ground floor to the front of the property, which was up graded when the proprietors took over providing a pleasant area to sit for residents. In addition, there is a reception room/quiet room, which is very Abbeyrose Nursing Home DS0000061145.V309685.R02.S.doc Version 5.2 Page 18 pleasantly decorated and furnished plus a conservatory to the rear of the property, which looks out onto the garden. The carpet in the conservatory needs replacing as it is stained. Although there are arrangements for heating and ventilation in the conservatory it was stated that it could get very hot and cold at times. This area will need to be reviewed. It was noticed that some of the chairs and over bed tables in the lounge/dining room were damaged and will need replacing. The existing garden is generally well maintained with a patio area and furniture to use when weather permits. The extension to the home has encompassed the property next door and some work is required on the garden area that joins the two properties. The clinical waste bins are situated to the front of the home and it was noted they were not locked. Under health and safety rules these should be kept locked. There is a combination of double and single rooms in the existing part of the home, which are furnished and personalised by some residents and their families. Two of these rooms have en-suite facilities; double rooms have privacy curtains fitted and locks have now been fitted to all bedroom doors to enable residents to lock them if they wish. During inspection it was noted that vanity units and wallpaper was damaged in some rooms and some pillows need replacement. All rooms are individually and naturally ventilated and windows are provided with restrainers. Radiators are of the low surface temperature type or covers are provided and water from hot water outlets is regulated to reduce the risk of scalding to residents There are assisted bathing facilities on each floor with a choice of bath or shower facility and it was noted that the extractor fans in some areas required cleaning. 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. On discussion with the member of staff there appeared to be some lack of clarity around the procedures and infection control procedures were generally poor. It was stated that this issue was being addressed. The kitchen required more thorough cleaning and foods that had been decanted into containers had not been consistently dated. Abbeyrose Nursing Home DS0000061145.V309685.R02.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to this service. Satisfactory staffing levels were being maintained to meet residents needs and training is on going. The recruitment procedure has improved ensuring that residents are adequately protected. EVIDENCE: The staffing rotas indicated there is adequate staff on duty with at least one nurse at all times, plus an acting manager Monday to Friday. Catering, and ancillary staff support the care staff and it was stated the agency staff are currently being used to maintain adequate staffing levels. On inspection of staff files they were found to be generally satisfactory with the appropriate checks. It was noted that CRB checks had been obtained from previous employers for a small number of staff who had been working in the home for a considerable period of time. The staff team is made up largely of Afro Caribbean and Asian staff. However, this does not reflect the cultural composition of the resident group who are mainly white European. It is recommended that when recruiting staff the cultural mix of the resident group is taken into consideration and staff from similar cultures recruited. Over 50 of care staff are trained to NVQ level 2, which meets the standards and it was stated that induction training is provided, but there was no record of Abbeyrose Nursing Home DS0000061145.V309685.R02.S.doc Version 5.2 Page 20 this. The acting manager must ensure there are records of induction training available and it meets the standards of the Social Skills Council. Abbeyrose Nursing Home DS0000061145.V309685.R02.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 38 Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to this service. The management arrangements with specific roles and responsibilities lacks clarity and communication systems need to be improved in order to improve outcomes for residents. A quality assurance system needs to be introduced and staff supervision enhanced. EVIDENCE: Currently there is an acting manager in post, who is a registered nurse. The proprietor will need to make arrangements for registration of a manger with the Commission. On discussion with staff they stated they got on well as a group and felt they worked as a team, but it became apparent that communication was lacking and some staff were not aware of various aspects of residents care needs. Abbeyrose Nursing Home DS0000061145.V309685.R02.S.doc Version 5.2 Page 22 Communication systems will need to be reviewed. Staff meetings are held intermittently and supervision sessions are being held with staff, but records were generally lacking in detail about the areas discussed. Although objectives were set there was no evidence that they had been achieved. Records of supervision require more detail of the areas discussed and progress with meeting objectives. Where necessary staff who are undertaking supervision should undertake training. Currently there is no formal quality assurance process. The acting manger stated he was in the process of writing to relatives in order to arrange meetings with them to discuss aspects of the home and the care of their relative. The proprietor visits on a regular basis, but there was no evidence of reports on the conduct of the home to demonstrate this. This area will need to be addressed and copies sent to the Commission. Since the last inspection there has been training in respect basic core training e.g. fire prevention, health and safety, infection control. The staff training file needs to be developed with certificates to demonstrate training undertaken. The following aspects in respect of health and safety were not satisfactory: • Fire doors were propped open • In house checks of the fire alarm system, emergency lighting and hot water temperatures had not been undertaken regularly • The insurers report for the passenger lift was not available • The electrical wiring certificate for the original part of the home was not available. • There was no evidence of the servicing of the hoist and bath seat. The home does not holed money on behalf of residents and invoices relatives for any extras such as hairdressing and chiropody. Abbeyrose Nursing Home DS0000061145.V309685.R02.S.doc Version 5.2 Page 23 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 1 2 2 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 2 14 1 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 3 3 X 2 2 3 1 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 3 2 X 2 Abbeyrose Nursing Home DS0000061145.V309685.R02.S.doc Version 5.2 Page 24 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, cover all areas outlined in the regulations and reflect changes in the home. Timescale of 30/11/05 not met. The registered person must ensure the service user guide is updated to reflect current arrangements in the home The registered person must ensure all residents receive a copy of the terms and conditions of residence and a copy is retained on their files. The registered person must ensure assessments are fully completed for all residents following admission to the home and the resident or their representative is involved in the process. Timescale of 30/8/05 not met. The manual handling assessment must be reviewed and include details of the action to be taken if a resident sustains a fall. Abbeyrose Nursing Home DS0000061145.V309685.R02.S.doc Version 5.2 Page 25 Timescale for action 30/12/06 2. OP1 4 30/12/06 3. OP2 5(1b) 30/10/06 4. OP3 14 30/10/06 5. OP4 18(1) 6. OP7 15 The registered person must ensure staff receive training in respect of caring for residents currently in the home with specific mental health disorders and dementia. Timescale of 30/8/05 not met. 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. Suitable arrangements must be in place to ensure staff are made aware of the contents of care plans and how to meet residents needs. The registered person must ensure the daily records accurately reflect the resident’s condition and the care provided. The registered person must undertake a review of the use of turn charts, fluid balance charts, food charts etc and ensure they are used effectively and completed accurately when in use. The registered person must ensure: • All residents requiring a wheelchair are referred for an assessment by an appropriate professional. Timescale of 30/6/05 not met. • Arrangements are put in place for monitoring of chronic diseases such as diabetes, hypertension etc and staff are provided with training where required regarding current practices. 30/12/06 30/10/06 7. OP7 17(2) 20/09/06 8. OP8 12(1) 20/09/06 9. OP8 13(1b) 18(1) 30/12/06 Abbeyrose Nursing Home DS0000061145.V309685.R02.S.doc Version 5.2 Page 26 10. OP8 12(1) 11. OP8 12(1) 18(1) 12. OP8 13(4) The registered person must: • Undertake a review of all pressure relieving equipment and ensure appropriate equipment is in use for all residents seeking advise from the tissue viability nurse. • Undertake an audit of handling equipment and ensure there is adequate equipment in the home to meet resident’s needs. • Follow up and ensure a suitable chair is obtained for resident. The registered person must ensure appropriate catheter care for all residents who have a urinary catheter in position and provide staff with training where required. The registered person must ensure bed rails are in use for residents following risk assessments. 30/11/06 20/09/06 20/09/06 Abbeyrose Nursing Home DS0000061145.V309685.R02.S.doc Version 5.2 Page 27 13. OP9 13(2) The registered person must ensure: • The medication room temperature is monitored and if above 25 C a more suitable air conditioning system installed to ensure the medicines are stored within their product licences. • The registered person must ensure the correct administration of all prescribed medication. Timescale of 30/12/05 not met. • Handwritten medication details must be countersigned to ensure the information is accurate. The amounts of medication entering the home are recorded consistently. The amount carried forward from previous months must be recorded on the new MAR chart. There must be a robust system for checking medication details when a resident is admitted to the home. The administration of antibiotics must be spread evenly over 24 hours. Nurses must administer nutritional supplements where prescribed. The amount of medication administered must be recorded when variable doses are prescribed. Residents who are selfadministering medication must have a risk assessment and regular monitoring undertaken. Creams must be prescribed, dated when opened and 20/09/06 • • • • • • • • Abbeyrose Nursing Home DS0000061145.V309685.R02.S.doc Version 5.2 Page 28 14. OP12 16(2m,n) 15. OP13 12(2)(3) 16. OP15 16(2i) 17. OP16 22 discarded after one month. Two members of staff must sign the receipt of controlled drugs. • Destroyed drugs must be stored in a locked cupboard • Oxygen must be secured and a statutory notice displayed. • The fridge temperature must be maintained within normal limits. The registered person must ensure: • An assessment of resident’s interests/hobbies is undertaken; a plan of activities is drawn up (group or individual) implemented and records maintained in the home. • Review the arrangements for seating in the lounge to enable the residents to see the television if they wish. The registered person must ensure all residents are consulted about their preferences in respect of the daily routine and how they spend time ensuring that action is taken to address their wishes e.g. getting up, going to bed bathing etc. The registered person must undertake a review of the arrangements for meal times and menus with a view to providing more choice plus cultural options. The registered person must ensure a record of all complaints indicates the nature of the complaint, the investigation, the outcome and resolution. • 30/11/06 20/09/06 30/09/06 30/09/06 Abbeyrose Nursing Home DS0000061145.V309685.R02.S.doc Version 5.2 Page 29 18. OP18 13(6) 19. OP19 23(2d) 16(2k) 20. OP19 13(3) 21. OP19 23(2o) 22. OP24 16(2c) 23. OP29 19 24. 25. OP30 OP31 18(1) 18(1) 9(2b,i) The registered person must ensure the adult protection procedures and whistle blowing procedures are updated and staff are provided with training to ensure they are fully conversant with the vulnerable adult procedures. The registered person must ensure: • All parts of the home are kept clean and odour free. • Undertake an audit of all rooms and decorate where required. The registered person must ensure: • The clinical waste bins are kept locked. • The laundry system is reviewed and adequate infection control procedures are put in place. The registered person must ensure the garden area is made suitable and safe for the residents to access. The registered person must: • Undertake an audit of all furnishings and replace any damaged items. • Replace the carpet in the conservatory. • Replace worn pillows The registered person must ensure a CRB check is undertaken for all staff working in the home. The registered person must ensure a record is retained in the home of all induction training. The Responsible individual must ensure an application for registration of a manger is forwarded to the Commission. 20/10/06 30/09/06 30/09/06 30/12/06 30/11/06 30/10/06 30/09/06 30/12/06 Abbeyrose Nursing Home DS0000061145.V309685.R02.S.doc Version 5.2 Page 30 26. OP33 24 27. OP32 12(1) 28. OP33 10(1) 29. OP33 26 30. OP36 18(2) 31. OP38 18(1) The registered person must ensure a suitable quality assurance process is implemented which includes feedback from stake holders and an annual development plan drawn up indicating outcomes for residents. The registered person must review the communication systems in the home and take appropriate action to address any short falls 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 ensure systems are in place for the production of a monthly report on the conduct of the home following visits and a copy forwarded to the Commission. Timescale of 30/6/05 not met. The registered person must ensure records of formal supervision are expanded to include all areas discussed at the time of meeting with follow up of objectives. Timescale of 30/12/05 not met. The registered person must ensure all staff undertake basic core training in respect of basic food hygiene, infection control, manual handling, fire prevention/drills and first aid. 30/03/07 30/09/06 30/01/07 30/09/06 30/10/06 30/03/07 Abbeyrose Nursing Home DS0000061145.V309685.R02.S.doc Version 5.2 Page 31 32. OP38 23(4) 33. OP38 13(4) The registered person must 30/09/06 ensure: • 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. • The fire alarm system is checked on a weekly basis. • The emergency lighting is checked on a monthly basis. The registered person must 30/10/06 ensure: • The bath hoist and seat are serviced on a regular basis. • The electrical wiring system in the original part of the home is checked regularly. • There is an insurers report for the passenger lift. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP16 OP25 OP38 Good Practice Recommendations It is recommended that a record of informal complaints/concerns are retained in the home Review the arrangements for the heating and ventilation in the conservatory. Draw up a training matrix to give an overview of the training staff have completed. Abbeyrose Nursing Home DS0000061145.V309685.R02.S.doc Version 5.2 Page 32 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.V309685.R02.S.doc Version 5.2 Page 33 - 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!