Inspection on 11/07/08 for Abbots Grange Residential Home

This inspection was carried out on 11th July 2008.

CSCI found this care home to be providing an Adequate service.

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

Abbots Grange Residential Home 07/07/09

Abbots Grange Residential Home 05/12/07

Abbots Grange Residential Home 19/07/07

Abbots Grange Residential Home 01/11/06

Abbots Grange Residential Home 28/02/06

Similar services:

Dystlegh Grange

Thornton Lodge

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Abbots Grange Residential Home Newport Street Werneth Oldham OL8 1RE Lead Inspector Sandra Buckley Unannounced Inspection 11th July 2008 09:30 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.V365480.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.V365480.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 F/P 0161 624 3752 Westholme Care Home Limited Mrs Carolyn Litherland 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.V365480.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). 5th December 2007 Date of last inspection Brief Description of the Service: Abbots Grange Residential Home provides 24-hour personal care and accommodation for up to 40 service users over the age of 65 years. Abbots Grange Residential Home is owned by Westholme Care Home Limited. 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 four shared bedrooms. En-suite toilets are provided in all the bedrooms, except five 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 £343. Further details regarding fees are available from the manager. Abbots Grange Residential Home DS0000065269.V365480.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes This was a key inspection that included a site visit to the home. The manager was not told beforehand that we were coming to inspect, this is called an unannounced inspection. This inspection looked at all the key standards and included a review of all available information received by the Commission for Social Care (CSCI) about the service provided at the home since the last inspection. During the site visit information was taken from various sources, including observing care practices and talking to people in the home. The manager and some members of the staff team were also interviewed. A tour of the home was undertaken and a sample of care, employment and health and safety records were seen. Comments from questionnaires returned from residents and their relatives are also included in this report. We require the home to complete an annual quality assurance assessment (AQAA) in order to demonstrate the level of care provided. The manager had completed this in full and comparisons were made with this document at the time of inspection. On this inspection the outcomes for people in the home did not always reflect that indicated by the manager in the AQAA, especially in relation to daily life and personal care. However, the manager had recognised what improvements could be made and was taking steps to address the issues. There have been two adult protection issues since the last inspection: one which is ongoing and one which was, in part, upheld, relating to the failure to get immediate medical attention after a fall. As a result of this, Oldham Metropolitan Borough Council’s Social Services Procurement Team are monitoring the situation. We have not received any complaints since the last inspection, although the manager had received one. We are satisfied that the manager took appropriate action and followed procedures in relation to complaints and the protection of vulnerable adults. Abbots Grange Residential Home DS0000065269.V365480.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Because of the wide age range of people accommodated in the home, the statement of purpose and service user guide must reflect how people’s needs would be met and what age range the home can accommodate, and include the complaints procedure. This will provide people with accurate information about what they can expect. The manager’s practice of taking records home must stop. Records relating to staff and residents (care plans) must be kept in the home so that anyone delivering care or seeking to review the care can look at the records. Care plans need to continue being developed and linked to people’s assessment of need. Abbots Grange Residential Home DS0000065269.V365480.R01.S.doc Version 5.2 Page 7 Medication records should be signed for at the point of giving a resident their medication and risk assessments need to be completed for those who selfmedicate. A more structured programme of activities in the home needs to be developed to ensure people’s stimulation. The hours worked by the manager and designations of staff must be reflected on the duty rota; this will clearly show who is on duty and what they are employed to do. The security of the building must be continually assessed in order to ensure people feel safe in their environment. Overall, the record keeping needs to be improved so that the manager can properly demonstrate the care which is being given. 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. The summary of this inspection report can be made available in other formats on request. Abbots Grange Residential Home DS0000065269.V365480.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.V365480.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 3. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The manager ensures an assessment of need is in place prior to people entering the home. EVIDENCE: Two files were examined in depth. Because of private funding, the manager had completed one and a professional assessment (from the local council) for the other one had been sought prior to the person moving into the home. The information provided was sufficient for the manager to be sure that the staff had the skills to meet the needs identified. A mixed age range of people is accommodated in the home. The statement of purpose and service user guide need to be updated to inform people what is available to meet the needs of people in a younger age group. Abbots Grange Residential Home DS0000065269.V365480.R01.S.doc Version 5.2 Page 10 The Annual Quality Assurance Assessment states that people are encouraged to visit the home prior to admission. One relative questionnaire said, ‘Information is available as and when needed from the manager and staff. Abbots Grange Residential Home DS0000065269.V365480.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9, 10 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. The lack of details in care planning and the absence of some records in the home potentially means that staff do not fully know what care is to be delivered, which could result in some residents’ needs remaining unmet. EVIDENCE: The manager had started to improve care-planning documents. These included dependency levels, nutritional risk and dietary preferences, with daily reports demonstrating the choices made. Weights of people were monitored and recorded. Two people’s case files were tracked from the time of their admission to the day of our visit. An additional two were looked at in relation to accident recording and adult protection issues. Abbots Grange Residential Home DS0000065269.V365480.R01.S.doc Version 5.2 Page 12 The assessment in one case was not reflected in care planning. The manager said this was on her computer at home for review and did reflect the care needed. The manager was advised that all information relating to residents must be retained in the home for staff reference and as an aid for staff to use to recognise symptoms that may occur in relation to the illness, for example, epilepsy. Other care plans; risk assessments and reviews provided information but were not signed and dated, making it difficult for anyone reading and using the information to be sure that it is up to date. The Annual Quality Assurance Assessment completed by the manager stated “we provide in depth information in care plans for each service user’s needs”. This was not always reflected at the time of this visit. Due to the lack of documentation held in the home for those people who were in a younger age group, there was no evidence that their particular educational and emotional needs had been addressed. The manager was unable to demonstrate this to us. One case file examined was linked to an ongoing protection of vulnerable adults investigation; however, no care plan was in place, which was linked directly to the person’s assessment of need. Observation of one resident highlighted the need for podiatrist treatment. However the service user’s file was not available for inspection in order to assess if this service had been requested. The senior carer on duty was not aware if the service had been requested and said she would discuss this with the manager, and would request treatment if not already done so. The recording of night checks had been implemented which showed if the resident was asleep on checking. Comments made on questionnaires from relatives said, ‘I can only speak for my dad they look after him well’ and ‘they are always there if needed’. Another said, ‘I know money is short but they could do with new wheelchairs and new beds’. There was evidence that the manager had started refurbishments to address this. Irregularities were found administering medication, recording as given, which medication that they have recording of medication. in medication procedures. One person was selfno risk assessment was in place and staff were clearly was not the case. Staff must not sign for not administered. We also noted some gaps in the Abbots Grange Residential Home DS0000065269.V365480.R01.S.doc Version 5.2 Page 13 No information was detailed on care plans regarding adverse reaction to drugs, for example, in the case of insulin. Staff we spoke with told us that they had been told to give a drink and that training had been arranged for managing insulin dependent diabetes. This training was going to be provided by the District Nursing Service. Examination of fridge stored drugs found five items out of date; one from May and four from June. Equipment in the home included standing hoist, moving belts, sitting chair, pressure mats and grab rails. Professional visits and hospital appointments were recorded. One resident said, ‘Staff are okay with me.’ Another said, ‘The dentist came here last week.’ The Annual Quality Assurance Assessment stated that 80 of staff had completed NVQ training. Abbots Grange Residential Home DS0000065269.V365480.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 15 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Some people’s needs are met on an individual level; there is a need for a more structured approach to ensure all needs are addressed. EVIDENCE: In assessing the quality of life that people experience in the home we found a mixed response. Care planning and daily reports examined did reflect people’s choice, for example, ‘One person wished to stay in bed this morning.’ One person interviewed said, ‘I did not feel well this morning, they advised me to have a lie down and they brought me a cup of tea.’ While we were talking to the manager one person came to the door requesting to change their toast at breakfast from white to brown bread. Another person had been assisted to change to an electric wheelchair to promote their independence. Abbots Grange Residential Home DS0000065269.V365480.R01.S.doc Version 5.2 Page 15 The Annual Quality Assurance Assessment completed by the manager stated, ‘Residents are offered a wide range of activities, such as exercise sessions, weekly sing-along, music afternoons, clothes parties, lunch trips out, card games and bingo. People at interview said, ‘Not much to do here.’ Another said, ‘There is not much going on here but I am happy with that.’ The manager had also recognised this on the Annual Quality Assurance Assessment stating ‘We are here to fulfil the needs of our service users with sufficient activities and, at times, this could be improved.’ One person had requested to do gardening. The manager had allotted a portion of the garden outside the person’s window for their personal use. The Annual Quality Assurance Assessment stated ‘We have introduced activities following talks with our service users, such as painting and arts and crafts. Work has been done in the garden carried out by residents and their families’. There was evidence that people were consulted through regular residents meetings. The last recorded meeting was on 17th July 2008. Out of 13 residents, nine had attended and two relatives. Requests made included a trip to Blackpool and more activities. One person said, ‘I have recently attended a meeting to discuss activities because there is not much going on here.’ Another person said, ‘Activities are down to staff and when they can do them.’ One person’s questionnaire, when asked how the home could improve, stated, ‘Taking people out for the day in summer as they are always in the day room or bedroom. It would do them good to get out in the fresh air.’ The manager said the hairdresser and beauty therapist attends the home on a weekly basis. People were complimentary about staff saying, ‘Staff treat me well’ and ‘Staff are great.’ We dined with people in the home; the meal on the day of the visit was fish and chips. There were no alternative choices reflected on the menu, however people were offered an alternative of egg and chips. One person said, ‘I only want cheese on toast for my tea, they only give me this because this is what I want.’ Another said, ‘the food is good here, we are certainly getting enough.’ Examination of the menu showed that out of 14 days, 12 teas consisted of soup and sandwiches and two days were pork pie or crumpets. We feel this is too repetitive. The manager said, ‘A small number of people in the home are able to tell staff of their preferences in respect of what they like to eat”. Abbots Grange Residential Home DS0000065269.V365480.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16, 18 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Improvements in staff training and the effective management of complaints show that residents are listened to and any concerns taken seriously. EVIDENCE: The manager recorded all complaints received. The last complaint was in relation to people in the home walking into each other’s bedrooms. The manger recorded the outcome and appropriate action had been taken in consultation with health care professionals. Although the complaints procedure was available to people, this was not included in the statement of purpose or service user guide. We have not received any complaints since the last inspection. One service user questionnaire said, ‘I have made complaints before and some have been put right, others have just been ignored. I have had complaints and kept them to myself.’ The manager had recognised on the Annual Quality Assurance Assessment that staff training regarding the management of complaints was needed. They stated that over the last 12 months 80 of staff had completed training in the protection of vulnerable adults and complaints had been dealt with effectively. Abbots Grange Residential Home DS0000065269.V365480.R01.S.doc Version 5.2 Page 17 One person said at interview ‘I would complain if I was not satisfied with anything.’ There have been two adult protection issues, one which is on going and one which was in part upheld, relating to failure to get immediate medical attention after a fall. As a result of this, Oldham Metropolitan Borough Council’s Social Services Procurement Team are monitoring the home. The manager demonstrated knowledge of the process to be used when dealing with situations in relation to the protection of vulnerable adults. Abbots Grange Residential Home DS0000065269.V365480.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 19, 26 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Work undertaken on the environment (which is continuing) has ensured that people live in a clean environment. EVIDENCE: Improvements have been made in certain areas. The manager stated on the Annual Quality Assurance Assessment that a higher standard of cleanliness has been maintained and maintenance records were completed to identify outstanding work. We noted that extra ancillary hours had been allocated to address issues raised about cleanliness on the previous inspection. At the time of this inspection there were no odours in the home. However, one person’s questionnaire said, ‘It can smell bad on some days.’ Abbots Grange Residential Home DS0000065269.V365480.R01.S.doc Version 5.2 Page 19 Other improvements include new bedroom furniture and carpets in some bedrooms. The manager stated on the Annual Quality Assurance Assessment that plans for the next year included introduction of quality assurance audits and the purchase of new garden furniture. The company’s maintenance person is allocated 50 hours between the three homes within the company. The manager said that once a person leaves a room the maintenance person redecorates the room and carpets cleaned or replaced. The manager has told us of burglaries at the home. This issue held a prominent position in the questionnaires returned from relatives and people in the home who said, ‘The security of the building could be better’, ‘my relative’s room was broken into by intruders who stole a substantial amount. There have been attempted break-ins on the premises since.’ Another person said, ‘Security of the building is not adequate and I do not feel safe.’ On the day of this unannounced visit, window locks were being fitted in order to reduce this risk. The manager had stated on the Annual Quality Assurance Assessment that more improvements to decoration of the building could be made. All communal areas were inspected and a selection of bedrooms. Bedrooms looked at had been personalised. People were offered keys to their bedroom doors and one person had chosen this option. Abbots Grange Residential Home DS0000065269.V365480.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29, 30 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Staff have access to regular training thereby ensuring staff are updating their skills in order to provide appropriate care to residents. EVIDENCE: The Annual Quality Assurance Assessment stated that 80 of staff had qualified to NVQ level 2 and that appropriate checks are undertaken prior to staff being employed to ensure the protection of people in the home. Also, staff meetings and supervision were held on a regular basis. All this information was validated on inspection through examination of records and staff interviews. Staff confirmed their attendance at meetings and the training they had completed or were waiting to attend. They were able to demonstrate and discuss the care needs of people in the home. In one instance, recruitment documents, for example, an application form, could not be found. The manager thought this might have been mislaid. We did evidence that appropriate Criminal Record Bureau checks take place before staff are employed, thereby ensuring only suitable staff are offered jobs at the home. Abbots Grange Residential Home DS0000065269.V365480.R01.S.doc Version 5.2 Page 21 The Annual Quality Assurance Assessment stated improvements had been made in the last 12 months to staff meetings and continuous monitoring. The duty rota did not reflect the hours worked by the manager or designations of staff. However, there was evidence that staffing levels had increased, especially ancillary hours, allowing carers more time to carry out their duties. There was evidence that staff training had been arranged with the district nurses for diabetes and pressure sore care. Staff at interview confirmed they had access to training and the manager said they work in partnership with Oldham Social Services Training Department. Abbots Grange Residential Home DS0000065269.V365480.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 38 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. The home is run by an experienced manager who has made many improvements in the provision of care to residents, however the lack of appropriate recordkeeping (which has been raised previously) detracts from the manager being able to fully demonstrate the care provided to residents and the efficient running of the home. EVIDENCE: The manager has been in post approximately 12 months. She has previous experience in management and care practices and has enrolled on the registered manager’s award. She told us that she participates in in-house training sessions with staff to update care practices. Abbots Grange Residential Home DS0000065269.V365480.R01.S.doc Version 5.2 Page 23 The manager has made a number of improvements while in post, as prior to this there were many issues to address - improvements have been made in the quality assurance, consultation with residents and families, and accident recording has improved. Some of the information the manager told us was in place when she completed the Annual Quality Assurance Assessment we did not find to be so. As mentioned earlier, some records we could not look at because the manager had taken them home. We did agree with the manager in terms of some of the matters she has told us they could do better – in particular, records keeping. The home has recently lost the safer food better business certificate. The manager said this was because of the lack of recording rather than related outcomes. The plans for the next 12 months are to continue staff training, supervision and appraisals also to introduce quality assurance audits. Health and safety was maintained through appropriate checks on gas and electrical equipment in the home. Fire checks were undertaken on a regular basis. Finances held on the behalf of people in the home were examined and found to match the recorded balances with receipts being retained for any expenditure. Abbots Grange Residential Home DS0000065269.V365480.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X 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 3 13 3 14 2 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 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 Abbots Grange Residential Home DS0000065269.V365480.R01.S.doc Version 5.2 Page 25 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 2 3 Standard OP7 OP7 OP8 Regulation 17 17 12 Requirement All records relating to residents must be kept on the premises. All records relating to staff must be kept on the premises. Arrangements must be put into place to ensure that health care needs, such as podiatry, are attended to in a timely manner. Risk assessments must be completed for people in the home who wish to self-medicate so that the manager is confident that any risks identified are eliminated/reduced. Timescale of 08/01/08 not fully met. Staff must sign the medication record at the point they give the medication to the person so they can be sure that medication has been given. Timescale for action 31/08/08 31/08/08 31/08/08 4 OP9 13 31/08/08 5 OP9 13 31/08/08 Abbots Grange Residential Home DS0000065269.V365480.R01.S.doc Version 5.2 Page 26 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 6 7 8 Refer to Standard OP1 OP7 OP9 OP9 OP12 OP16 OP19 OP27 Good Practice Recommendations The home’s statement of purpose and service user guide should state the categories and age range the home can provide care for and how people’s needs will be met. Care plans need to be linked to the person’s assessment of need, and should be signed and dated. Unused medication should be returned to the chemist. Staff should not sign for medication they have not given. Stimulation for people in the home should continue to be addressed to maintain improvements already made in daily life for people in the home. Ensure that the complaints procedure is included in the statement of purpose and service user guide. Continue to monitor security of the building in order to ensure people’s safety in the home. Staff duty rota should show the designations of people working in the home and the number of hours worked by the manager. Abbots Grange Residential Home DS0000065269.V365480.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Manchester Local Office Unit 1, 3rd Floor Tustin Court Port Way Preston PR2 2YQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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. 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