Inspection on 13/06/06 for Abbeywood

This inspection was carried out on 13th June 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 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

Abbeywood 24/10/06

Abbeywood 19/01/06

Abbeywood 10/08/05

Abbeywood 15/09/04

Abbeywood 17/05/04

Abbeywood 17/02/03

Similar services:

The Shelley

Thorndene

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

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

CARE HOMES FOR OLDER PEOPLE Abbeywood Abbeywood Wharf Road Ash Vale Surrey GU12 5AX Lead Inspector Sandra Holland Unannounced Inspection 13th June 2006 10:00 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 Abbeywood DS0000013544.V295483.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Abbeywood DS0000013544.V295483.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbeywood Address Abbeywood Wharf Road Ash Vale Surrey GU12 5AX 01252 317132 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) Anchor Homes To be confirmed Care Home 50 Category(ies) of Dementia - over 65 years of age (21), Old age, registration, with number not falling within any other category (12), of places Physical disability over 65 years of age (15) Abbeywood DS0000013544.V295483.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The age/age range of the persons to be accommodated will be: 65 YEARS AND OVER, with one (1) named resident aged 64 years. Up to twenty-one (21) residents may be within the category DE(E) Dementia - over 65 years of age. Up to fifteen (15) residents may be within the category PD(E) Physical Disability over 65 years of age. 19th January 2006 Date of last inspection Brief Description of the Service: Abbeywood is a purpose built home located in the residential area of Ash Vale and is located next door to the local health centre. The Home is managed by the Anchor Homes Trust and is registered to care for 50 residents over the age of 65. A Manager, Deputy Manager and a team consisting of care staff, catering, domestic, administration and maintenance staff are employed to meet the needs of residents. The home is divided into five separate units each comprising of a lounge/dining room with its own kitchen area where refreshments can be provided. Residents are accommodated in single bedrooms that are all close to communal bathroom and toilet facilities. The home has a private, central courtyard garden that is secure and accessible to residents. A limited amount of car parking is available for visitors. The fees at Abbeywood range from £650.00 to £750.00. Abbeywood DS0000013544.V295483.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was the first “key” inspection to be carried out in the Commission for Social Care Inspection (CSCI) year April 2006 to June 2007, and was carried out under the CSCI’s Inspecting for Better Lives programme. As the inspection was unannounced, no-one at the home knew it was to take place. Mrs Sandra Holland, Lead Inspector carried out the inspection over nine hours. Mrs Alexandra Strong, Manager was present representing the service. A full tour of the premises was carried out and a number of records and documents were examined, including staff files, care plans , medication administration record (MAR) charts and health and safety records. Fourteen residents, four visitors and thirteen members of staff were spoken with. A visiting healthcare professional was also spoken with at some length. A pre-inspection questionnaire was supplied to the home and was completed and returned within the requested timescale. Some of the information from the questionnaire will be referred to in this report. The people living at the home prefer to be known as residents and that is the term that will be used throughout this report. The inspector would like to thank residents, staff and management for their hospitality, time and assistance. What the service does well: The home is cheerfully decorated and well furnished and presents as a comfortable place to live. An attractive courtyard garden, which is safely enclosed is available for residents’ use. Residents and visitors spoke highly of the welcome they receive and of the helpfulness and commitment of staff. The staff are responsive to changes in residents’ health and seek prompt and appropriate advice. An effective working relationship is held with the local health centre. Abbeywood DS0000013544.V295483.R01.S.doc Version 5.2 Page 6 Residents said they felt safe in the home. What has improved since the last inspection? What they could do better: It is recommended that all parts of the pre-admission assessment form are completed, even if to show that they do not apply. Care plans must contain all the required information. Medication must not be signed for until after it has been administered. The corporate complaints policy must be reviewed and it is recommended that any complaints are recorded on numbered forms to enable them to be traced. It is recommended that a more stimulating lounge environment is provided for residents with increased dementia needs. A full employment history must be obtained for all applicants for employment at the home and any gaps must be fully accounted for. Staff must receive training to enable them to fulfil their role. The activities co-ordinator must receive training specific to her role and this must be suited to meet the needs of people with dementia. The manager’s application for registration must be completed. It is recommended that two signatures are obtained for all transactions of residents’ monies held for safekeeping. Abbeywood DS0000013544.V295483.R01.S.doc Version 5.2 Page 7 Doors designed to close automatically in the event of the fire alarm being activated must not be wedged open and products hazardous to health must be stored in a locked provision. 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. Abbeywood DS0000013544.V295483.R01.S.doc Version 5.2 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 Abbeywood DS0000013544.V295483.R01.S.doc Version 5.2 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 and 6. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ needs are fully assessed before they move into the home. EVIDENCE: From the records seen and speaking to residents, it was clear that the needs of residents had been fully assessed before they had moved into the home. A number of residents had been assessed under the care management process, as they are supported financially by a local authority. Where this was the case, the home had obtained a copy of the assessment and kept this on file. It was pleasing to see that staff from the home had also met with residents before admission and had carried out their own assessment. The manager stated that she and the deputy manager carry out assessments of prospective residents and the records confirmed this. It was noted that some areas of the home’s own assessment were left blank and the deputy manager advised that these were not applicable. It is recommended that an entry is made in all areas of the home’s own pre-admission assessment, even if this is to indicate Abbeywood DS0000013544.V295483.R01.S.doc Version 5.2 Page 10 that it does not apply, as this indicates that the area has been considered and not overlooked. The manager stated that intermediate care is not provided at Abbeywood. A recommendation has been made regarding Standard 3. Abbeywood DS0000013544.V295483.R01.S.doc Version 5.2 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 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Individual plans of care have been drawn up, but these do not contain all the required information. Residents healthcare needs are well met. Medication administration was not carried out according to procedure. Residents were treated with respect and their privacy was promoted. EVIDENCE: The manager stated that all the individual care plans were in the process of being reviewed and updated. From the individual plans seen it was noted that some did not contain the full information needed to guide staff to the support and care needs of residents. The personal details sheet for one resident had not been fully completed and did not record the religion, any allergies or the key people related to the resident. It was clear from the records seen and speaking to staff and residents that residents healthcare needs are well met. A number of healthcare professionals are involved in the support of residents, including general practitioners (GP’s), community nurses, a chiropodist and community psychiatric nurses (CPN’s). The manager advised that the CPN had provided Abbeywood DS0000013544.V295483.R01.S.doc Version 5.2 Page 12 the home with information leaflets regarding different behaviours to support staff in the care of residents with dementia and to assist with staff development. A healthcare professional who visited the home from the adjacent health centre made positive comments about the home, stating that it provided a good standard of care to residents and that timely and appropriate referrals were made in the event of changes to residents’ health. It was pleasing to hear that there is an effective working relationship between the home and the health centre. Medication in the home is administered to residents on the individual units where they live and this was seen in progress. It was noted that two staff administering medication signed the record chart and book to indicate that the medication had been administered, before it had actually been given to the resident. This was discussed with the staff and they agreed that the home’s procedure states that the signature should not be entered until after the resident had taken the medication. It was then noted that one of the members of staff did the same thing again, marking the MAR chart to confirm administration of the medication that was then given to the resident. This is poor practice and as it was repeated in front of the inspector, this could indicate that this may have been a regular practice. Staff were seen to treat residents with respect, speaking in a relaxed and friendly but appropriate manner. Resident’s privacy was promoted, with staff taking care to knock on resident’s bedroom doors before entering and providing personal care in a tactful and discreet way. Requirements have been made regarding Standards 7 and 9. Abbeywood DS0000013544.V295483.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are offered a range of activities although those for residents with dementia need to be developed further. Residents are supported to maintain contact with their families and friends and to make their own choices. A wellbalanced diet is provided. EVIDENCE: The manager stated that the activities co-ordinator had recently been appointed, and whilst she has not yet had training specific to the activities role, she has worked at the home for a number of years in a care role. Training for the activity co-ordinator role is to be arranged, the manager advised. A weekly activities programme has been arranged and was seen displayed on the unit notice boards. Information regarding activities was listed in the preinspection questionnaire and included in-house activities such as quizzes, arts and crafts, church services, cheese and wine tasting, skittles and seniorcise and outings including to the local garden centre, to local shops and to other places of interest in the area. Abbeywood DS0000013544.V295483.R01.S.doc Version 5.2 Page 14 It was observed that activities were not specifically arranged to meet the needs of residents with dementia, although residents with these needs are the largest category within the home. To ensure that the social and cultural needs of these residents are met, the training to be undertaken by the co-ordinator must include activities for people with dementia. Visitors to the home said that they were always made welcome and are offered refreshments. A number of visitors were seen in the home during the inspection and they spoke appreciatively of the care provided and of the kindness of staff. Staff were seen to offer residents choices and to encourage residents to be independent wherever possible. The deputy manager advised that one resident in the home does not speak English, but that staff have gradually come to know her likes and dislikes and have been supported by the residents family to learn a small number of essential words. Staff also observe the resident’s facial expressions and body language to assess her responses. The staff group in the home are culturally and racially diverse, but this is not generally reflected in the resident group. The lunchtime meal which was served on the day of inspection appeared appetising and wholesome. There was a choice of two main courses, both of which were offered to residents to enable them to make a choice. The chef advised that further alternatives, including a salad or filled jacket potato were also available to residents, if preferred. It was pleasing to see that the chef visited the unit dining rooms during the lunch service to monitor the popularity of the meals and the residents’ responses. The chef advised that specialist diets can be accommodated and currently diabetic and pureed diets are provided in addition to the main menu. The pureed diets served to residents were attractively presented, with the food items individually pureed to retain their colour. Abbeywood DS0000013544.V295483.R01.S.doc Version 5.2 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 the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are confident that their complaints will be listened to and will be acted on. Staff are aware of their responsibilities in the protection of residents. EVIDENCE: A complaints policy and procedure is available in the home and is supplied to residents in their service user’s guide, the manager stated. Reference to the management of complaints was also seen in the home’s statement of purpose. The manager stated that the complaints policy on display is the Anchor organisation’s corporate policy which is currently being reviewed. This has not yet been completed and this was confirmed at a recent meeting between CSCI and the managing director of Anchor Homes. From speaking to residents and visitors it was clear that they felt able to approach staff or the manager with any complaints that they had and it was pleasing to hear residents state that they feel safe in the home. The complaints record was seen and the last entry was made five months ago. This had been signed by the manager and recorded the actions taken. It was noted that the complaint forms had been numbered but the forms available for use were not numbered. It is recommended that numbered forms are used so that these can be traced and to ensure accurate recording. Abbeywood DS0000013544.V295483.R01.S.doc Version 5.2 Page 16 The deputy manager stated that regular resident meetings are held and provide another opportunity for residents to air their feelings about the home or to raise any issues. Minutes of a recent residents’ meeting were seen on the unit notice boards. Staff spoken to stated that they would report any concerns they had about the abuse or potential abuse of residents, to the manager or the senior in charge, and would not hesitate to do so. A number of staff advised that they had received training in the safeguarding of adults and in the rights and responsibilities of residents. To safeguard residents’ finances, only administrative or senior staff have access to this and residents are provided with a lockable facility in their bedrooms, in which to store their valuables. A requirement and a recommendation have been made regarding Standard 16. Abbeywood DS0000013544.V295483.R01.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 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home presents as a comfortable place in which to live and was clean, tidy and appeared hygienic. EVIDENCE: Overall the home was seen to be well maintained and attractively decorated in a range of colours. An enclosed courtyard garden was accessible from a number of areas of the home. This was planted with seasonal plants and flowers and was equipped for the warmer weather with chairs, tables and sun umbrellas. The manager advised that the outside of the home was being decorated and this was seen in progress. Scaffolding had been erected around the building to enable the decorators to access the upper floor and residents and a visitor commented that this had made some rooms dark. Abbeywood DS0000013544.V295483.R01.S.doc Version 5.2 Page 18 It was pleasing to see that the home had a specific, sensory stimulation room, in which residents could enjoy a range of sights and sounds and this is situated on the unit for more dependent residents with dementia. The lounge on this unit however was noted to be rather bare, with only one or two pictures on the walls, which were not very distinct for residents with poor sight. A television and a music system were available for residents to enjoy. The armchairs did not have any scatter cushions to aid individual comfort and there were few ornaments. It is recommended that a range of stimulating items are provided to create interest and topics of conversation for residents. All areas of the home were clean and tidy and appeared hygienic. Handwashing facilities with liquid soap and paper towels are provided in all appropriate places and staff were seen to use these. The laundry is situated at the front of the building at the end of a unit corridor and is away from food preparation and serving areas. It is well equipped with the appropriate facilities and an allocated member of laundry staff. A recommendation has been made regarding Standard 19. Abbeywood DS0000013544.V295483.R01.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 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A team of staff are employed to meet residents’ needs. Residents must be more fully protected by the home’s recruitment practices. Staff training and record keeping must be improved. EVIDENCE: From the information provided with the pre-inspection questionnaire, it was clear that a full team of staff are employed to meet all the needs of the residents. These include care staff, kitchen staff, housekeeping staff, a handyperson/gardener, an activities co-ordinator, receptionists and administrators. The manager provide information during the inspection regarding the number of staff who have achieved National Vocational Qualifications, to level 2 or higher. As nine staff have achieved this and a further eight are currently undertaking this, the home is working towards the recommended fifty per cent of qualified staff. Although most of the required recruitment records and documents have been obtained, it was noted that a full employment history had not been obtained for two staff. For one member of staff, their employment history started in 1990, although documents providing the employees age would indicate a much Abbeywood DS0000013544.V295483.R01.S.doc Version 5.2 Page 20 longer working life. For another member of staff, their employment history started at age twenty-six. It is required that a full employment history is obtained and any gaps must be fully accounted for. Individual staff training records are maintained and these were seen. It was noted that for one member of staff who had been employed for over six months, no training record was held. There were no records of induction present for this member of staff and another member of staff employed for a similar period. A requirement was made at the inspection carried out on 19th January 2006, that the activities co-ordinator must receive training specific to that role. This requirement has been met, but will now be carried forward as the previous activities co-ordinator has moved to another role. A new activities co-ordinator has been appointed and also requires training for the role. From speaking to kitchen staff, it was apparent that they require training in first aid, particularly as the kitchen has many potential hazards. The chef stated that he had carried out this training in the past, but not for a number of years. Requirements have been made regarding Standards 29 and 30. Abbeywood DS0000013544.V295483.R01.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 and 38. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The manager’s application for registration with CSCI must be completed. The record keeping regarding residents’ monies held for safekeeping should be strengthened and some aspects of the health and safety of residents must be improved. EVIDENCE: The manager stated that she was appointed to the home in October 2005, that she has a number of years experience in care and was a deputy manager prior to this position. The manager has submitted her application for registration with CSCI and this is currently being processed. A quality assurance survey was carried out in January of this year, by an independent company the manager advised. This was supplied to all of the residents and forty-four representatives of residents. It was disappointing that Abbeywood DS0000013544.V295483.R01.S.doc Version 5.2 Page 22 no responses were received from residents, but twenty-three responses were received from representatives. Of the thirty-six areas measured, the home scored above average for twenty-one of these and below for fifteen. The report provides guidance as to the weak areas to assist with improvement. It was pleasing to see that five very positive comments were received and all of the respondents said they would recommend the home to others. A full report was produced and a copy was supplied, as is required, to the inspector. A system is in place in the home, for the storage and management of residents’ monies held for safekeeping. The amounts held were checked with the records held and these accurately matched. It was noted that the record sheets for residents’ monies transactions has provision for two signatures, but for most transactions only one signature has been recorded. It is recommended that the signatures of both parties involved in the transaction are recorded to safeguard residents and staff. Some aspects of the safety, health and welfare of residents need to be improved. It was observed that a cupboard containing hazardous products in one of the unit kitchens was found to be unlocked with the key in the door. A number of products hazardous to health were stored in the cupboard and residents, some of whom may have dementia, were not being prevented from accessing these. It was also observed that in a number of locations around the home, doors designed to close automatically in the event of the fire alarm being activated, were wedged open, preventing closure. Doors wedged open included the laundry, the manager’s office and the activity room. A door wedge was seen beside a door to the kitchen, indicating that it is propped open at times. These are unsafe practices and potentially place those in the home at risk. Requirements have been made regarding Standards 31 and 38 and a recommendation has been made regarding Standard 35. Abbeywood DS0000013544.V295483.R01.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 x x 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 3 2 x x x x x x 3 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 3 x 2 x x 1 Abbeywood DS0000013544.V295483.R01.S.doc Version 5.2 Page 24 NO 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 2 Standard OP7 OP9 Regulation 15 13 Requirement Resident’s care plans must contain the required information and be kept under review. Medication must be safely administered and recorded. Medication administration record charts must not be signed until the medication has actually been administered. The home’s corporate complaints procedure must be reviewed and be suited to the needs of the residents. A full employment history must be obtained from all applicants for employment at the home and any gaps must be fully accounted for. Staff must receive training appropriate to the work they are to perform. Specifically, the activities co-ordinator must receive training for this role, to include provision for people with dementia and the kitchen staff must receive first aid training. The manager’s application for registration with CSCI must completed DS0000013544.V295483.R01.S.doc Timescale for action 14/07/06 13/06/06 3 OP16 22 08/09/06 4 OP29 19 Sch 2 13/06/06 5 OP30 18 08/09/06 6 OP31 9 08/09/06 Abbeywood Version 5.2 Page 25 7 OP38 13 All parts of the home to which 13/06/06 residents have access must be free from hazards to their safety. Specifically, doors designed to close automatically when the fire alarm is activated must not be wedged open and products hazardous to health must be stored in a locked provision. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 Refer to Standard OP3 OP9 OP16 OP19 OP35 Good Practice Recommendations It is recommended that all sections of the pre-admission assessment are completed and marked with not applicable where that is the a case. It is good practice for handwritten entries on MAR charts to be checked and countersigned by a second member of care staff. It is recommended that any complaints received are recorded on numbered forms for ease of tracking. It is recommended that a more stimulating lounge area is provided for residents with increased dementia needs. It is good practice for two people to sign to show that they have been involved in the handling of resident monies transactions. The signatures should be recorded in the spaces specifically provided on the resident monies record sheet. Abbeywood DS0000013544.V295483.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Abbeywood DS0000013544.V295483.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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. 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