Inspection on 19/07/07 for Abbots Grange Residential Home

This inspection was carried out on 19th July 2007.

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

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

Other inspections for this house

Abbots Grange Residential Home 07/07/09

Abbots Grange Residential Home 11/07/08

Abbots Grange Residential Home 05/12/07

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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Abbots Grange Residential Home Newport Street Werneth Oldham OL8 1RE Lead Inspector Sandra Buckley Unannounced Inspection 19 July 2007 09:30 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.V343900.R02.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Abbots Grange Residential Home DS0000065269.V343900.R02.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 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.V343900.R02.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). Date of last inspection Brief Description of the Service: Abbots Grange is a residential home providing 24-hour personal care and accommodation for 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, 13 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 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 £328. Further details regarding fees are available from the manager. Abbots Grange Residential Home DS0000065269.V343900.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced visit was made to the home on the 19th July 2007. means the manager did not know we were coming to do an inspection. This This inspection looked at all the key standards and 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. The home has not had a registered manger or a period of sustained management for some time. A new manager had been in post for only ten weeks. Application to register the manager has not yet been submitted to the CSCI, which is now a matter of urgency. During the site visit information was taken from various sources, which 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 by residents and their relatives are also included in this report. Four of the requirements from the last inspection had not been addressed in full. There still remained a number of service development issues to be addressed. The CSCI requires the home to complete an annual quality assurance assessment (AQAA) in order to demonstrate the level of care provided. Comparisons are made with this document at the time of inspection which, in this instance, found that outcomes for people in the home did not reflect that indicated by the home, especially in relation to daily life, staffing levels, personal care and protection. We did not agree with the manager’s assessment of the service provided. What the service does well: The manager obtains an assessment of people’s needs from professionals or completes their own assessment for people who are self-funding. Abbots Grange Residential Home DS0000065269.V343900.R02.S.doc Version 5.2 Page 6 Some care plans recorded people’s preferences, likes and dislikes and, where possible, people’s interests had been detailed. One person said “Staff look after us well” and “Staff are nice to me”. Staff showed an understanding of how to maintain people’s privacy and dignity. One person said, “Staff help me to bath and respect my privacy. What has improved since the last inspection? What they could do better: People need to be provided with accurate information regarding services in the home. This will allow them to make sure that the service provided is what they are looking for. The manager said this information was being reviewed and updated. Care plans and risk assessments need to be completed in full and reflect the assessed needs of people. The completion of such information properly will provide staff with sufficient information to carry out their duties. Medication storage and administration must improve, especially when medication is brought into the home by people coming in for a short stay. Risk assessments must be in place for those people who self-medicate. This will show that the manager has considered that in continuing to self-medicate neither the resident nor anyone else is at risk from this practice. . Risks were also identified in the environment with the lack of radiator covers. In the event of beds being placed in close proximity to radiators, risk assessments should be carried out. Again, the manager needs to be sure from undertaking such risk assessments that no-one is at risk from accidental burning from these uncovered radiators. Abbots Grange Residential Home DS0000065269.V343900.R02.S.doc Version 5.2 Page 7 Equipment placed near fire exits also posed a risk to people in the home, as it is possible that people could not leave the building safely in the event of a fire. Staffing levels must be reviewed to ensure the needs of people are met. This would also allow care staff to undertake social activities with people. One person said, “I would like to go out but staff say they have not got time.” Staff had received training in moving and handling, which is now outdated and a refresher course is needed. The manager is undertaking lots of different duties, such as cooking and cleaning. This has resulted in some of management duties not being carried out as well as they should be. The manager needs to recruit extra staff so they can carry out such duties and allow her time to manage the home better. Employment, recruitment and vetting practices were unsafe. The manager could not show us all the right documents to demonstrate to us that she had taken up all the proper checks on staff to make sure they were suitable to be working with older people. The manager needs to make sure she has references in place, and police checks completed before she employs anyone, and evidence of this must be available to us. 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.V343900.R02.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.V343900.R02.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): Standards 1 & 3 Quality in this outcome area is good. Assessment of need is obtained from professionals to enable the home to assess if people’s needs can be met. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: The statement of purpose and service user guide were being upgraded to reflect developments in the home. A copy of the recent inspection report should also be available for relatives and people in the home to read. One person said, “I did not receive information about the home before I came in because I had to come as an emergency.” Abbots Grange Residential Home DS0000065269.V343900.R02.S.doc Version 5.2 Page 10 Three assessments of need were examined in depth. One was for a selffunding person that the manager had completed and the other two were from professionals. All provided sufficient information for the manager to be able to make an informed decision that the staff at the home had sufficient skills in which to meet the assessed needs. Abbots Grange Residential Home DS0000065269.V343900.R02.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. Failure in care planning and care delivery means that people may be at risk. Shortfalls identified in the medication system potentially places people at risk. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: People in the home were neatly presented. Attention had been paid to nails and hair, and ladies wore tights if this was their preference. Comments from people in the home included ‘staff are nice to me’ and ‘staff look after me well.’ People receive health care visits from professionals, for example, district nurses. One person said, ‘a podiatrist comes to do my nails.’ Recording of daily care notes was good but health care visits had not been recorded in full. Abbots Grange Residential Home DS0000065269.V343900.R02.S.doc Version 5.2 Page 12 Examination of three care plans linked to the assessments of people recently admitted found these to be incomplete. In two instances, no care plan was in place. The third did not reflect the person’s assessed needs nor give implicit instructions to staff on care delivery. Several other files were looked at which also required updating. Risk assessments were not completed in full; weights had not been recorded on admission or recorded on a regular basis. One person had a history of falls, notably in the evening and during the night. No action had been taken in the provision of aids to alert staff. Nor had the manager undertaken an analysis of falls or a risk assessments to prevent or reduce the number of falls this resident was having. The manager said that the present staffing levels resulted in her having to do the cooking which left insufficient time for record keeping. Observations throughout the day found that staff delivered personal care in private. During interviews staff demonstrated a good knowledge of how privacy and dignity should be maintained for people in the home. One person said, ‘Staff are good and help me bathe in private.’ Staff were efficient in providing care to people, although interactions with people were focussed on the task in hand. The inspector interviewed three people who were sat outside in the sunshine and were without sunscreen and protective covering. This clearly presents a risk of burning to these residents. One person was being moved in a wheelchair without footplates, which also presents a risk of falling. The manager said the person was more of a risk with footplates. However, there was no evidence that this risk had been assessed or discussed with other professionals involved in care and was not reflected in care planning. Several staff had undertaken moving handling training a long time ago and now required professional updates. Irregularities were found in the storage, recording and administration of medication. In one instance, a person required cream to be applied to their skin. While interviewing the person in their room, the inspector found the tub of cream to be empty, as a replacement had not been ordered. Other people were observed to be self-medicating; no risk assessments were in place to demonstrate that they were able to undertake such a task and that in doing so they did not place anyone at risk. Abbots Grange Residential Home DS0000065269.V343900.R02.S.doc Version 5.2 Page 13 Medication that was required to be stored in a fridge was held in the drug cabinet. Open boxes of medication had not been dated on opening, making a timescale to discard the medication difficult to assess. Some people who had come into the home for short stay were receiving medication brought in a cassette by their relatives. The home should ensure that a pharmacist has dispensed medication in order to ensure accountability. Abbots Grange Residential Home DS0000065269.V343900.R02.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 & 15 Quality in this outcome area is adequate. Social activities and stimulation need to improve to ensure the diverse needs of all people are met. Routines and task-focussed services do not always promote people’s choice. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: There was evidence of some good practice in linking people’s preference with care plans. However, these were not always completed in full, an example being: one person did not sleep well at night and wished to stay in bed in the morning. Daily notes also showed that during the night they were offered tea and sandwiches. One person was an artist, with the home having purchased sketching materials which they were working on at the time of this visit. Abbots Grange Residential Home DS0000065269.V343900.R02.S.doc Version 5.2 Page 15 Activities of people in the home relied on staff availability. Observations made throughout the day found that staff were task orientated, leaving little time for recreational work. One person said, ‘I asked to go out but staff said they haven’t got time.’ The inspector spoke to a group of people. One person said, ‘I go to bed at 9:45 but I can go any time.’ My wife and I have put weight on since we came here, the food is good.’ Another said, ‘People in the home are happy and contented.’ Three people chose to stay within their rooms, others coming in the dining room for meals. One person said, ‘I am happy with my hi-fi, I prefer to be in my room listening to music.’ One relative questionnaire said, ‘the home seems to be dealing with my sister’s problems as she prefers not to be with other people.’ Several people said food had improved under the new manager. Menus are planned on a four-weekly cycle. The manager had also compiled advice regarding dietary issues relating to other cultures. There was no-one in the home requiring a special diet at the time of this inspection. The inspector sampled food of the day, which was tasty and presented in an appetising manner. However, the food served was not that which was stated on the menu. Teatime should have been a choice of hot food, with people being given sandwiches. When asked why, staff said that the manager cooks and because of the inspection she was unavailable. Staffing levels and routines in the home need to be reviewed in line with the numbers and dependency levels of people in the home. Staff are observed to be discreet when offering help to those who need assistance during meal times. Abbots Grange Residential Home DS0000065269.V343900.R02.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 & 18 Quality in this outcome area is good. People were confident that they would be listened to if they had any concerns. Staff training in the protection of vulnerable adults ensured people were protected from abuse. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: Since the last inspection, no complaints had been received by CSCI or the home. One person said, ‘If I had any concerns, I would see staff.’ The complaints procedure had been upgraded to reflect appropriate timescales for action. Staff at interview demonstrated a good knowledge of how abuse may occur when dealing with people with special needs. They were aware of what forms this may take and their responsibility for reporting any such event. Staff had received training in the protection of vulnerable adults. Abbots Grange Residential Home DS0000065269.V343900.R02.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 & 26 Quality in this outcome area is adequate. People live in a generally clean and tidy home. The lack of risk assessments for exposed radiators and blockages near fire exits may pose a risk to the safety of people in the home This judgement has been made using available evidence, including a visit to this service. EVIDENCE: A selected tour of the premises took place that included all residents’ bedrooms, communal areas and some of the newly furnished rooms. Abbots Grange Residential Home DS0000065269.V343900.R02.S.doc Version 5.2 Page 18 It was noted that some rooms were without radiator covers. This is a particular concern when beds are placed in close proximity to radiators. No risk assessments had been completed. The tour took place during the afternoon and, in many instances, floors were still untidy and needed cleaning. Staff said they had not had chance to get to the rooms because they delivering care. The home has no dedicated domestic to ensure standards are maintained. This situation must now be reviewed in order to provide an holistic approach, ensuring people have a pleasant environment they can return to in privacy away from communal living. A hoist and mattress were stored near fire exits that could pose a risk to people in the home, in that, this may restrict quick and easy access out of the home in the event of a fire. A number of people had chosen to bring in personal items from home. The home had given consideration to the needs of a married couple living in the home in the provision of adjoining rooms, one of which had twin beds in and the other used as a private sitting room. They said they were very pleased with this. The spacious environment and large lounge and dining room allowed people to move around freely. The lounge was bright, clean and tidy with pleasant views over the garden. However, aspects of the garden required attention. Those people who were interviewed in their rooms were satisfied with their accommodation. A handyman is available for carpet cleaning and minor repairs. Some refurbishments had been started in the home and new furniture purchased for a selection of bedrooms. Abbots Grange Residential Home DS0000065269.V343900.R02.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 & 30. Quality in this outcome area is poor. The process for recruiting staff was not undertaken fully and did not offer protection to people living in the home. The deployment and number of staff available is not sufficient to meet the needs of people. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: At the time of this inspection 13 people were being accommodated in the home. Examination of the duty rota found that, in some instances, staff were working long hours, for example, 4:00pm till 8:00am the following morning. This potentially means that staff become very tired. This practice needs to be reviewed with some urgency. In addition, there were only two staff and a manager on duty till 5:00pm, which then reduces to two staff in the evening and night duty. This number reduces to two staff all through the day at weekends. In addition to delivering personal care and administrating medication, care staff have to carry out bed changes, laundry, cleaning, cooking and washing the pots. Abbots Grange Residential Home DS0000065269.V343900.R02.S.doc Version 5.2 Page 20 The current staffing level for 13 residents is not considered to be sufficient, and this is supported by our evidence, in that, the manager is unable to fulfil her management duties as she is undertaking other tasks, and care staff have limited time to spend with residents on recreational activities as they are busy undertaking care and cleaning tasks. On a previous inspection the number of people accommodated had been seven. At that time, the manager had been asked to provide written information to the CSCI regarding how staffing levels would be increased in line with numbers and the dependency levels of people coming into the home. We could find no evidence that this had been done. The inspector acknowledges that one person had been employed to undertake cleaning duties at weekend between 8:00am and 2:00pm. This person was under 18 years of age and was aware that they should not undertake personal care. The staff files of two newly recruited staff were looked at. The manager had not undertaken all the necessary checks to ensure the protection of people living there. In one instance, the application form and relevant checks could not be found. The other file contained evidence of a Criminal Record Bureau check but the start date had not been recorded. This made it difficult to assess if this had been obtained prior to employment. Also, no reference could be found. A core of staff had worked at the home a number of years, providing some continuity of care for people. These staff had undertaken NVQ level 2 training. Other training required updating, for example, moving and handling. Staff inductions were in line with Skills for Care and the manager said they were in discussion with Oldham Social Services training department to improve staff training. One person’s questionnaire returned said, “I like all the staff”. Abbots Grange Residential Home DS0000065269.V343900.R02.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 36, 37 & 38 Quality in this outcome area is poor. The home is not being managed properly to ensure people receive consistent quality care. This results in some practices that do not promote the health, safety and welfare of people in the home. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: The home has had a succession of managers over a period of time, none of which had submitted and application to be registered with the CSCI. This has impacted on the development of the home. Abbots Grange Residential Home DS0000065269.V343900.R02.S.doc Version 5.2 Page 22 The manager at the time of this inspection had been in post approximately ten weeks and has over twenty years’ experience in care and management. She said she has applied to undertake the registered manger’s award. An application for registration with the CSCI has not yet been submitted. A number of issues have been identified throughout this report, which indicate the home has not been managed properly. This is especially so in relation to record keeping, care planning and medication issues. Recruitment procedures were not safe enough to ensure the protection of people in the home. Staffing levels and deployment had not been reviewed in line with the increased number of residents or their needs. The practice of some staff working long hours potentially poses a health and safety risk to people in the home. No staff meetings or supervisions had taken place. The manager said discussions had taken place informally and the supervision process had been set up ready to commence. She also said that, at present, care work was task orientated, i.e., cooking, cleaning and helping with personal care when needed and that they were doing this in order to assess standards and staff capabilities. A review of staffing levels needs to take place in order for the manager to undertake her statutory duties and meet the requirements made in this report. There was evidence that the manager had begun to identify equality and diversity issues through menu planning, providing advice to staff on the dietary needs of other cultures. The manager said they were aware of the task required and the need to address management issues. The manager completed the Annual Quality Assurance Assessment required by the CSCI. However, although completed well, this did not reflect the standards and practices in the home. A sustained period of management is now required in order to address issues identified in this report. Staff said they felt supported by the new manager. Quality assurance systems had been implemented, with questionnaires being sent out for completion. The financial records of two people living in the home were examined and found to balance with monies held on their behalf. Receipts were retained for proof of purchase. Abbots Grange Residential Home DS0000065269.V343900.R02.S.doc Version 5.2 Page 23 Interviews with staff showed that up to date training in moving and handling procedures was required. Fire exits were blocked with stored equipment, posing a risk to people in the home. Records were maintained of checks to equipment, i.e., hoist, gas and electrical equipment. Fire alarm tests were carried out on a regular basis. Quality assurance systems had been implemented, with questionnaires being sent out for completion. Abbots Grange Residential Home DS0000065269.V343900.R02.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 2 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 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 1 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 1 X 3 2 1 2 Abbots Grange Residential Home DS0000065269.V343900.R02.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 Standard OP7 Regulation 15 Requirement Timescale for action 31/08/07 2 OP8 Care plans of people in the home must reflect their assessment of need and provide detailed instructions to staff on care planning. 12, 14, 15 When people are susceptible to falls during the night, equipment, e.g., pressure mats must be in place to alert staff and ensure people’s health and safety. Accidents must be recorded in full with analysis. Risk assessment must be completed if footplates are not used when moving and handling people in wheelchairs to ensure their safety and protection. 31/08/07 Abbots Grange Residential Home DS0000065269.V343900.R02.S.doc Version 5.2 Page 26 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. 3 Standard OP9 Regulation 13 Timescale for action The registered person shall make 31/08/07 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. (Timescale of 31/03/07 not met) Medication and topical creams must be ordered in sufficient time to ensure people receive their medication as prescribed. Risk assessments must be completed when people in the home wish to self-medicate. Medication must be stored as directed by the pharmacists. Care and ancillary staffing levels must be increased to ensure the health and welfare of people is not adversely affected. Staffing levels must reflect the numbers of people and their dependency levels. Requirement 4 OP27 18 30/09/07 Abbots Grange Residential Home DS0000065269.V343900.R02.S.doc Version 5.2 Page 27 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. 5 Standard OP29 Regulation 19 Requirement The registered person must 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. (Timescale of 310/3/07 not met) Two references must be sought and Criminal Record Bureau checks undertaken to ensure the protection of people living in the home. Timescale for action 31/08/07 Abbots Grange Residential Home DS0000065269.V343900.R02.S.doc Version 5.2 Page 28 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 Refer to Standard OP1 OP9 Good Practice Recommendations People in the home should be provided with an up to date service user guide, with the inspection report being accessible to them. The date of opening must be written on medication which states a short expiry date, to ensure people’s health and safety. A pharmacist must dispense medication brought into the home by relatives for people on respite care. Equipment in the home should be stored away from fire exits. Risk assessments should be completed on all radiators without guards. Staff should not work excessive hours, e.g., 4pm to 8am, in order to ensure the health and welfare of people in the home is maintained. Staff must complete an up to date course in moving and handling. The manager should be provided with additional supernumerary hours in order to carry out their statutory duties. OP9 OP19 OP27 OP30 OP31 Abbots Grange Residential Home DS0000065269.V343900.R02.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Manchester Local Office 11th Floor West Point 501 Chester Road Manchester M16 9HU 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. Extracts may not be used or reproduced without the express permission of CSCI - 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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