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Inspection on 01/11/06 for Abbots Grange Residential Home

Also see our care home review for Abbots Grange Residential Home for more information

This inspection was carried out on 1st November 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.

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

What has improved since the last inspection?

Care planning documentation had improved although further work in some areas is required. Equipment such a hoist and sit on scale was now available in the home and this enables care to be provided over a range of care needs. Staff have had NVQ training and training in other areas which they said they had enjoyed and they felt this had helped them improve the service they provided. Staff said they had received training to meet different care needs of the residents living at the home. Parts of the home environment on the ground floor continued to benefit from refurbishment. Recording of complaints has been undertaken and details of action taken in response to these were available. Records of resident`s money was safe.

What the care home could do better:

The owner must ensure that in the absence of a manager that standards in the home do not slip, and this includes standards of care planning and cleanliness in the home. Employment recruiting and vetting practices were unsafe in that criminal disclosures (police checks) or Povafirsts had not been consistently obtained before the new employee started work in the home. This means that people living in the home are potentially not protected from someone with a criminal or abusive background. Care plan evaluations and monitoring of falls must be undertaken to ensure residents changing needs are monitored and treated. Care plan interventions could be made more person specific to records are available of each resident`s preferences and wishes. Consideration should be given to increasing staffing in the home to ensure standards of cleanliness are maintained and this would enable care staff to undertake social activities with residents. Additional duties such as cleaning in the home were not prioritised resulting in parts of the home needing vacuuming. Medication recording practices must improve and care staff need training in the safe administration of medication. Staff also need up to date training in fire safety.Quality assurance systems need to be developed or implemented more fully and systems to check the quality of care plans and medication practices. Cleaning systems should be reviewed to ensure all rooms are kept smelling clean and fresh. Menus should be reviewed to ensure that the nutritional content is in line with the government recommendations. This will ensure that residents receive a balanced and nutritious diet. The home`s information guides should include information about the terms and conditions of residency and a copy of the summary of the last inspection should be readily available in the home. This will ensure that residents have full information about the home and the conditions under which they reside.

CARE HOMES FOR OLDER PEOPLE Abbots Grange Residential Home Newport Street Werneth Oldham OL8 1RE Lead Inspector Tracey Rasmussen Unannounced Inspection 1st November 08:40 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 Abbots Grange Residential Home DS0000065269.V309439.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. Abbots Grange Residential Home DS0000065269.V309439.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbots Grange Residential Home Address Newport Street Werneth Oldham OL8 1RE 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) 0161 624 3752 0161 624 3752 Westholme Care Home Limited Catherine Bezer Care Home 40 Category(ies) of Dementia - over 65 years of age (15), Old age, registration, with number not falling within any other category (30), of places Physical disability over 65 years of age (10) Abbots Grange Residential Home DS0000065269.V309439.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 40 service users to include: *up to 15 service users in the category of DE(E) (Dementia over 65 years of age). *up to 30 service users in the category of OP (Old age, not falling within any other category). *up to 10 service users in the category of PD(E) (Physical disability over 65 years of age). The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social care Inspection. 28th February 2006 2. Date of last inspection Brief Description of the Service: Abbots Grange is a residential home providing 24-hour personal care and accommodation up to 40 service users over the age of 65 years. Abbots Grange has recently been bought and is now owned by Westholme Care Home Limited. At the time of this inspection, 7 residents were accommodated and the home had undergone a programme of redecoration and refurbishment. The home is situated on a quiet residential street in Werneth, approximately one mile from Oldham town centre. Local shops and a doctor’s surgery are about a ten minute walk away. Buses are available to Oldham and Manchester from Manchester Road, which is a ten-minute walk away. A small drive leads to the home, which was once a large Victorian house. To the side of the property is a small garden area. A car park is available to the front of the home. The home has been extended to the rear to provide accommodation for up to 40 service users. Bedroom accommodation is provided on both the ground and first floors. The home also has a mezzanine level but access to these bedrooms is restrictive, due to steps. There are 32 single and 4 shared bedrooms. En-suite toilets are provided in all the bedrooms, except 5 rooms. There are two lounges and one dining room on the ground floor. The home has one assisted bath, one unassisted bath and one shower room. The current weekly fees are £313.88. Further details regarding fees are available from the manager. Abbots Grange Residential Home DS0000065269.V309439.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection which included a site visit was undertaken by one inspector on the 1st November 2006 and was completed in the course of one day. The inspection included a review of all available information received by the Commission for Social Care Inspection (CSCI) about the service provided at the home since the last inspection. All key inspection standards were assessed at the site visit and information was taken from various sources which included observing care practices, talking with residents; speaking with visitors and members of the staff team. A tour of the home was also undertaken and a sample of care, employment and health and safety records seen. Staff reported that the manager of the home was annual leave and following this would leave the employment at the home. During the time at the home the manager had improved almost all aspects of the service offered. Most of what we asked the manager to do following the last inspection have been done. The registered provider was in the process of recruiting a new manager. What the service does well: The home was peaceful and offered a relaxed pleasant atmosphere. Staff were friendly and good humoured with residents and visitors to the home and they undertook their caring duties in a professional manner. One resident said, ‘I am looked after’ and a relative said ‘he is being really well looked after’ and ‘it’s the best place for him here –he is warm and well fed throughout the day’. Information about the home and the services provided was available at the entrance and in bedrooms. Residents and a relative were complimentary about living in the home and praised both the manager and staff. Residents appeared well cared for with attention to hair, nails and clothing coordination and there was friendly banter and camaraderie between residents and staff. The home had seven residents and there was 2 care staff on duty at all times. Due to the low occupancy in the home care staff also did domestic and cooking duties. The staffing levels at this visit did seem appropriate to ensure residents got the care they needed. Abbots Grange Residential Home DS0000065269.V309439.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The owner must ensure that in the absence of a manager that standards in the home do not slip, and this includes standards of care planning and cleanliness in the home. Employment recruiting and vetting practices were unsafe in that criminal disclosures (police checks) or Povafirsts had not been consistently obtained before the new employee started work in the home. This means that people living in the home are potentially not protected from someone with a criminal or abusive background. Care plan evaluations and monitoring of falls must be undertaken to ensure residents changing needs are monitored and treated. Care plan interventions could be made more person specific to records are available of each resident’s preferences and wishes. Consideration should be given to increasing staffing in the home to ensure standards of cleanliness are maintained and this would enable care staff to undertake social activities with residents. Additional duties such as cleaning in the home were not prioritised resulting in parts of the home needing vacuuming. Medication recording practices must improve and care staff need training in the safe administration of medication. Staff also need up to date training in fire safety. Abbots Grange Residential Home DS0000065269.V309439.R01.S.doc Version 5.2 Page 7 Quality assurance systems need to be developed or implemented more fully and systems to check the quality of care plans and medication practices. Cleaning systems should be reviewed to ensure all rooms are kept smelling clean and fresh. Menus should be reviewed to ensure that the nutritional content is in line with the government recommendations. This will ensure that residents receive a balanced and nutritious diet. The home’s information guides should include information about the terms and conditions of residency and a copy of the summary of the last inspection should be readily available in the home. This will ensure that residents have full information about the home and the conditions under which they reside. 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. Abbots Grange Residential Home DS0000065269.V309439.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 Abbots Grange Residential Home DS0000065269.V309439.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): 1 and 3 Quality in this outcome area is good. Residents are supplied with up to date information about the services the home offers and so can make a fully informed decision about the suitability of the home. Assessments undertaken prior to admission ensure that the home can meet the needs of the resident. This judgment has been made using available evidence including a visit to the service EVIDENCE: A Statement of Purpose and Service User Guide, which are information guides that explain what services and facilities the home offers to people were available in the unoccupied bedrooms of the home. A professionally printed information sheet was also available to all visitors, at the main entrance to the home. Abbots Grange Residential Home DS0000065269.V309439.R01.S.doc Version 5.2 Page 10 The information provided was clearly written and detailed but a copy of the home’s terms and condition of residency and the summary of the last inspection should also be included with the information. Three resident care files were seen and these contained detailed information about each of the residents care needs. The care records included information that indicated that the home had made pre-admission assessments or checks on the resident’s care needs before they came into the home. This enabled the manager of the home to assess whether the new resident’s care needs could be met properly by the services provided in the home. Other professional assessments from social workers and from community nurses were also available on the residents care files. This information provided a more detailed picture of the new resident’s care needs and enabled the home to prepare for the arrival of the new resident. The home had written care plans detailing the type of care and support that would be required in response to the identified needs from these assessments. Residents and their relatives spoken with were very positive about the home. One relative of a newer resident in the home said ‘‘Staff approach seems very caring’ and ‘he is being really well looked after’ and one resident said ‘I am looked after’. Abbots Grange Residential Home DS0000065269.V309439.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 good. Residents receive care and support in a respectful and dignified manner. The care planning documentation was sufficient to meet the personal and health care needs of residents. Shortfalls identified in the medication system, potentially places residents at risk.. This judgment has been made using available evidence including a visit to the service EVIDENCE: The home provided care and support to seven residents at this visit. Almost all residents were spoken with during the inspection visit. Those that could provided positive comments about living in the home. One resident stated that staff “are very kind” and ‘I am more settled here that some places’. Another resident said it’s ‘fairly good here but not home’ and a relative said – Abbots Grange Residential Home DS0000065269.V309439.R01.S.doc Version 5.2 Page 12 ‘the staff accommodate (my loved one’s) needs’ and ‘he is encouraged to maintain his independence’. Residents were presentable and dressed according to their preference, clothing co-ordinated, hairs were set and fingernails were manicured. The home was calm and peaceful. Staff chatted with residents in a calm relaxed manner and there was good camaraderie observed between residents and staff. Staff were respectful, attentive and caring in their approaches and interactions with residents. Staff demonstrated clear understanding about each resident’s personal care needs and preferences. Three care plans were viewed and these contained assessment information based on the activities of daily living, moving and handling, nutritional, falls, skin and Waterlow assessments. Where a risk or need was identified then a care plan was recorded. The majority of the care plans seen had very good care plan interventions which explained how care was to be given according to the diverse needs and wishes of the resident (person centred care). Care plans also included references to promoting privacy and dignity. Falls risk assessments had been recorded, however the evaluation of these did not include reference to the number of falls the residents had had each month and therefore to did not provide an accurate plan of action to manage or limit the number of falls. Records of contact with community health services to meet individual care needs were available and these included, GP, podiatry and dementia care team. Medication recording practices were not always safe. Records of all medication entering the home were not consistently recorded. This means that the home could not track the amount of medication in the home. Signatures by staff were not recorded when they added or changed the medication record sheet. The staff team had not had training in the safe administration of medication to residents. This must be provided to all staff who help resident’s with medication to ensure practices do not put residents at risk of receiving incorrect medication. Staff said that the manager had enabled them to obtain their NVQ 2. Since the last inspection over half of the care staff had almost completed their NVQ 2 and staff had benefited from other training such as dementia. Abbots Grange Residential Home DS0000065269.V309439.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 adequate. Life style choices were available and resident’s family and friends were welcome in the home at any time although not all resident’s social needs were met. The quality of food provided is satisfactory and in line with residents preferences. This judgment has been made using available evidence including a visit to the service EVIDENCE: Staff provided care and assistance to residents at a time and pace to suit the residents. One resident’s preference to have his meals later than traditional meal times was respected. Staff also had a good awareness of each of the resident’s social backgrounds and personal likes and wishes in relation to living in the home. The home was currently staffed with two care staff who cooked the meals for residents and undertook cleaning duties in the home. Staff confirmed that Abbots Grange Residential Home DS0000065269.V309439.R01.S.doc Version 5.2 Page 14 they seldom had time to undertake planned activities with residents because they had to undertake their other duties. Staff did spend time chatting with residents and friendly banter was observed between staff and residents. One resident said when asked about activities ‘there is a paper if they want it: there are books and we have little sing a longs’. Another resident said, ‘No there are no games, we sit in a chair all day long’. Care plan records of social needs were available in the care files seen and these did refer to the resident’s social assessment and preferences. During this visit many visitors called at the home and they made themselves ‘at home.’ One relative said ‘I visited other homes and I wasn’t impressed’ and ‘the best place for him here – he is warm and well fed’ The home has a two week rolling menu which is available in the kitchen. Staff said they usually made meals in accordance with resident’s preference. It was unclear if nutritional guidelines were used in menu planning and the menus should be reviewed in line with government recommendations in providing balanced nutrition. The home offers an hot cooked breakfast, main lunchtime meal, lighter tea and supper. Lunch was egg, chips and beans followed by fruit pie and custard. All residents tucked into the meal and appeared to be enjoying it. A range of comments were received from residents and these included; ‘Food is brilliant’; ‘I’ve put weight on’; ‘Food is alright’ ;‘I don’t like the food and ‘Food is like a 4 star hotel’. Staff confirmed and proud, to state that they had all completed Safer Food Better Business training provided by Environmental Health, which means the food service practices in the home are safe. Abbots Grange Residential Home DS0000065269.V309439.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. Residents can be confident that staff are trained to respond appropriately to suspected abuse and residents can also be confident that all complaints will be treated seriously. This judgment has been made using available evidence including a visit to the service EVIDENCE: Since the last inspection visit the manager had received a number of concerns and issues and had addressed these through the home’s complaints procedure. Records were available of all complaints and issues and the actions undertaken in response to each complaint was recorded. A resident said, ‘no worries –I’d tell staff if I had any complaints’ and ‘I’ve no issues or problems’. Staff reported that they had received training in abuse and the protection of vulnerable adults and were able to discuss the content of their training and relate it to the home environment. Staff also confirmed they had undertaken NVQ training and this also included information and training in abuse. Abbots Grange Residential Home DS0000065269.V309439.R01.S.doc Version 5.2 Page 16 The Commission For Social Care Inspection (CSCI) has not recevied any complaints about the services since the last inspection. Abbots Grange Residential Home DS0000065269.V309439.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 adequate. Residents live in a generally clean and tidy home that has benefited from a programme of maintenance, redecoration and refurbishment. Specialist equipment is available thereby promoting independence and safe practice for residents. This judgment has been made using available evidence including a visit to the service EVIDENCE: All residents were living on the ground floor of the home. A programme of redecoration and refurbishment has continued in the home. Bedrooms on the ground floor have been redecorated and new soft furnishing provided. New bedroom furniture has also been provided in some rooms. Bedrooms on the mezzanine and first floor were not viewed because they were not occupied. Abbots Grange Residential Home DS0000065269.V309439.R01.S.doc Version 5.2 Page 18 Bedrooms were personalised with possessions from home. One resident said, ‘My little treasures on the windowsill are from home’ and another resident said, ‘my bedroom is pokey compared to home’ Essential equipment such as a hoist and “sit on scale” were also available at this visit. A new central heating boiler had been fitted and the owner reported that the ground floor bath which was faulty was being replaced with a shower unit in approximately five weeks. A couple of bedrooms were odorous and staff reported that they were waiting for a new carpet cleaner. Parts of the home were in need of a good vacuuming. Staff said they usually undertook cleaning duties when time permitted. At this visit, visitors, both personal to residents and professional were seen coming and going – care staff did not have time to undertake cleaning duties. The owner should consider employing a domestic cleaner for a few hours each week to ensure the home remains clean and presentable. Abbots Grange Residential Home DS0000065269.V309439.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. Staffing levels, training and skill mix were appropriate to meet residents’ needs and promote their health and safety. Recruitment vetting procedures were unsafe putting residents at risk of potential harm. This judgment has been made using available evidence including a visit to the service. EVIDENCE: The home had seven residents and staffing levels were maintained at two care staff throughout a 24 hours. Care staff also had responsibility for cooking and cleaning in the home. Given the resident’s dependency levels and care needs staffing levels were sufficient at this visit to meet personal care needs. However, the owner should give some consideration to providing some cleaning or cooking hours in the home to enable social activities to be undertaken. A visitor said that ‘staff approach seems very caring’ and residents said, ‘Staff are very, very kind’ and ‘most are respectful and friendly; others are not.’ Staff had had training since the last inspection visit. A number of the team had literally completed their NVQ 2, staff had had training in abuse, dementia , Abbots Grange Residential Home DS0000065269.V309439.R01.S.doc Version 5.2 Page 20 moving and handling and health and safety. Training in fire safety had not been provided and this should be provided as soon as possible. The manager had worked hard since the last inspection where no staff member had an employment file; most of the older staff team had employment files and Criminal Record Disclosures (CRB). A sample of personnel files were examined for a number of newer staff to the home. A number of areas of improvement were needed this included ensuring application forms were completed fully, full employment histories recorded and gaps in employment explored. Evidence that CRBs and PovaFirsts had been obtained before the commencement of employment was not available on some of the files examined. This means that the home is unaware if some of the staff in the home has a criminal history or if there is a potential threat to vulnerable residents. Abbots Grange Residential Home DS0000065269.V309439.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): 33, 35 and 38 Quality in this outcome area is adequate. The management of the home promotes the health, safety and wellbeing of the residents. Residents have had limited opportunities to comment on how the home is run and systems to monitor and improve service quality could be better. Arrangements are in place to ensure resident’s money is safe. This judgment has been made using available evidence including a visit to the service. EVIDENCE: Standard 31 could not be assessed because the manager was on annual leave and was then leaving the home. The manager has made a significant impact in improving the quality of service provided in the home and both staff and visitors were positive about the manager. Abbots Grange Residential Home DS0000065269.V309439.R01.S.doc Version 5.2 Page 22 The owner of the home was in the process of interviewing to recruit a new manager for the home. This is a priority as the standards in the home are likely to drop without management and leadership. Evidence that quality assurance systems had been implemented in the home was not available. Residents and relatives both stated that they could talk to the manager with their issues or concerns and systems to improve the quality of care following a complaint was in place. However systems to monitor and improve service quality do need developing and implementing. Resident’s personal monies were held securely and records were available, and these were recorded accurately. Health and safety records were available. The home employs a part time maintenance person to undertake health and safety tasks such as fire safety testing and monitoring. Comprehensive work place risk assessments were available and these were supported by policies and procedures. Abbots Grange Residential Home DS0000065269.V309439.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 2 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x x x x 2 STAFFING Standard No Score 27 2 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x 1 x 3 2 x 3 Abbots Grange Residential Home DS0000065269.V309439.R01.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 OP8 Regulation 12,14,15 Requirement The registered person must ensure that falls assessments are evaluated appropriately to include reference to the number of falls a residents has had and the assessment should detail the action taken to reduce the number of falls. Timescale for action 31/12/06 2. OP9 13 3 OP29 19 The registered person shall make 31/12/06 arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. This includes -ensuring that all handwritten additions to the MAR sheet are signed and dated by the person making the addition; recording the receipt of medication into the home. The registered person must 15/12/06 ensure that all information and documents stated in Schedule 2 of the Care Homes Regulations 2001 are obtained in respect of employees at the home and must ensure that checks against the POVA list are made prior to employment. DS0000065269.V309439.R01.S.doc Version 5.2 Page 25 Abbots Grange Residential Home 3. OP30 18, The registered person must ensure staff receive adequate and timely training in all aspects of the service they provide and this includes: training which is accredited in the safe management of medication and fire safety 30/12/06 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 OP1 Good Practice Recommendations The registered person should ensure that the Service User Guide contains a copy of the summary of the last inspection report and a copy of the home’s terms and conditions of residency. The registered person should ensure that care plans are personalised with specific person centred preferences and evaluations are meaningful. The registered person should ensure that regular activities, stimulation and one to one time is spent with each resident and this is recorded in their plan of care. The registered person should ensure that the nutritional content of meals provided in the home conform with government guidelines for basic nutrition. The registered person should ensure that equipment such as carpet cleaners are readily available in the home so that carpet soiling can be cleaned immediately. The registered person should consider employing someone to undertake cleaning duties to assist care staff in ensuring and clean and pleasant home environment is provided. The registered person should ensure quality assurance monitoring systems are implemented in the home and a copy of the regulation 26 monitoring visit record is supplied to the CSCI. 2. 3 4 5 6 OP7 OP12 OP15 OP26 OP26 7 OP33 Abbots Grange Residential Home DS0000065269.V309439.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Ashton-under-Lyne Area Office 2nd Floor, Heritage Wharf Portland Place Ashton-u-Lyne Lancs OL7 0QD 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 Abbots Grange Residential Home DS0000065269.V309439.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. 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