Inspection on 27/04/06 for Abbots House

This inspection was carried out on 27th April 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 House 05/03/07

Abbots House 10/01/06

Abbots House 10/08/05

Abbots House 06/12/04

Abbots House 29/06/04

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

CARE HOMES FOR OLDER PEOPLE Abbots House 103 Abbots Road Abbey Hulton Stoke on Trent Staffordshire ST2 8DJ Lead Inspector Wendy Snell Key Unannounced Inspection 27 April 2006 9:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Abbots House DS0000028862.V292816.R01.S.doc Version 5.1 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 House DS0000028862.V292816.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Abbots House Address 103 Abbots Road Abbey Hulton Stoke on Trent Staffordshire ST2 8DJ 01782 234888 01782 232938 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) Stoke on Trent City Council Miss Melanie Joy Fenton Care Home 39 Category(ies) of Dementia (5), Dementia - over 65 years of age registration, with number (39), Mental Disorder, excluding learning of places disability or dementia - over 65 years of age (6), Physical disability over 65 years of age (39) Abbots House DS0000028862.V292816.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 5 Dementia (DE) - Minimum age 55 years on admission Date of last inspection 10th January 2006 Brief Description of the Service: Abbots House is a Local Authority older people’s home which provides care for people with a dementia and similar mental health problems. The home is operated by Stoke-on-Trent Social Services and can accommodate up to 39 people with varying dependency needs. The home has three beds to provide short-term care. There is an attached day centre that caters for a maximum of 25 people and some of the residents of Abbots House like to spend time in the day centre, enjoying the activities and the stimulation that this provides. Located in Abbey Hulton, the home is a two-storey property providing all single bedrooms (although at the time of this inspection a married couple were sharing a large single bedroom, which had formerly been a double bedroom). There are four separate living areas, each having a lounge-dining room, with adjacent bedrooms, bathroom and toilets. First floor accommodation is accessed by a lift. Externally there is a car park and the rear garden offers an enclosed area for residents. The location of this home ensures that there is a wide range of community facilities nearby that can be readily accessed. Abbots House DS0000028862.V292816.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection, which took place on a Thursday from 9am to 5.45pm. During the inspection a number of service users, a visitor, staff and the acting manager were spoken with. Prior to the inspection the Commission for Social Care Inspection (CSCI) had sent out comment cards to service users and relatives. Eight relatives comment cards were sent back to CSCI. What the service does well: What has improved since the last inspection? Some redecoration has taken place since the last inspection and a new care planning system has been implemented. Abbots House DS0000028862.V292816.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Abbots House DS0000028862.V292816.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Abbots House DS0000028862.V292816.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 The home does not consistently have assessments of service users’ needs, which enable staff to support them appropriately. The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service users in this home have dementia. Some service users were able to comment on their care in general terms however; information for this area was gained primarily through observation, reading documents and discussions with staff. Four service users’ files were examined. These included three permanent service users and one service user who was having a short stay. It was noted that one service user did not have an assessment of their needs on file. It was therefore unclear what information the staff were using to plan care and meet needs in relation to this service user. This was discussed with the acting manager. A subsequent discussion with a staff member established that a staff member intended to speak with a relative to gain information about the service user. This is good practice and provides added secondary information, however, a care management assessment of needs must be in place prior or Abbots House DS0000028862.V292816.R01.S.doc Version 5.1 Page 9 on admission for all service users to provide staff with the information to meet the needs of individual service users. Abbots House DS0000028862.V292816.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Care planning and assessment needs to be more comprehensive to adequately identify and reflect how staff are to meet service users needs on a daily basis. The systems for the administration of medication are generally good. The potential impact that cigarette smoke within the home has on service users’ quality of life should be considered. The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Four service users care plans were examined. Two service users had completed care plans in place, however two service users had very brief information relating to how their care needs were to be met. One of these service users did not have an assessment as discussed in standard three of this report. Observations of one service user who was having a short stay at the home noted that he required quite a lot of staff interaction to ensure that his needs were met and that he was safe. However, both assessment and care planning information was limited and did not include information about the personal history or routines of the service user or how staff were to manage potential areas of risk. Areas of concern had been noted in the communication records Abbots House DS0000028862.V292816.R01.S.doc Version 5.1 Page 11 but there was no risk assessment in place in respect of these concerns. Good assessment and care planning are vital tools to enable staff to meet the needs of people with dementia. This area must be addressed. The pre-inspection questionnaire completed by the acting manager states that the health needs of the service users at Abbots House are met by eight local GP practices. A number of service users have maintained the services of the GP they had prior to moving to Abbots House. A sample of four service user files were examined all contained information relating to health professionals involved in the service user’s care. Eight relatives completed a CSCI questionnaire prior to the inspection. Seven stated that they were satisfied that staff kept them informed of important matters affecting their relatives. One relative however, raised concerns about an incident in 2005 where she had not been informed that her mother had received hospital treatment for a fall. This may have been an oversight on the part of the staff however, it is recommended that the manager reviews the communication mechanisms within the home when a service user receives hospital treatment. The home has a smoking room. On the day of the inspection the smoke from the smoking room could be smelt in other parts of the building including in a lounge which is situated nearby. There are also a number of bedrooms in close proximity. It was noted that the door to the smoking room was not always closed and although there is an extractor fan within the room this did not appear to be effective in preventing smoke circulating around the ground floor of the home. A number of service users when asked stated that they had never smoked. This was discussed with the manager who was advised to consider ways in which the service users within the home can be better protected from cigarette smoke within the building. It was noted that the home have appropriate continence to ensure service users continence needs are met. There were appropriate disposal units within the home which reduces the risk of cross infection. Information regarding service users dietary needs and weight charts were noted to be on service user’s files. Staff stated that service users are weighed monthly or more frequently if there are any concerns. In checking the service users files it was noted that there was a lack of consistency in doing this with one service users chart not completed for 2006 and another not completed since January 2006. Regular weight recording and monitoring must take place to ensure that any unusual loss or gain is appropriately acted upon. The pre-inspection questionnaire completed by the acting manager states that there are eight staff responsible for the administration of medication and that safe handling of medicines training had taken place over the past 12 month period. Administration of medication was observed during the inspection. The staff member appropriately checked medication and the medication administration record. Medication was administered in a sensitive manner and Abbots House DS0000028862.V292816.R01.S.doc Version 5.1 Page 12 service users were observed by the staff member to take their medication. The staff member stated that she had received medication training. In January 2006 four service users were spoken with about how the home upholds their privacy and dignity. All service user spoken with were able to express an opinion, some were able to offer more detail than others. In a discussion about bathing one service user said that staff ‘always make it as private as it can be’. She clarified this point by explaining that bathing is never completely private because they require staff assistance. All the service users agreed that staff always close the door to bathroom or toilet facilities when assisting service users in these areas. One service user raised concerns about limited access to privacy in his bedroom. Another service user said that they can have a lie down during the day if they ‘tell staff they are tired’. In view of the service users cognitive difficulties the inspector is unclear how this system works for all service users on a daily basis. The acting manager stated that this issue is due to be addressed within the home on a risk assessment basis with a number of service users having free access to their bedrooms. This will be reviewed at the next inspection. Three staff members were asked about privacy and dignity and how it informed their practice. All stated that they covered this on the NVQ training. The staff members were able to give example of practice such as bathing and delivering personal care where particular attention was paid to this area. Staff were observed prompting service users regarding their continence. This was done discreetly and sensitively, however, it was noted that staff entered the lounge and dining areas wearing protective blue gloves. This is not good practice and poses a cross infection risk. Abbots House DS0000028862.V292816.R01.S.doc Version 5.1 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 & 15 A range of activities and entertainment is offered to service users. Relatives views about visiting the home and the care their relatives receive were positive. The meals in this home are good offering both choice and variety however further consideration should be given to the specific dietary needs and requirements of people with dementia. Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. EVIDENCE: During the inspection visit, which took place between 9am, and 5.45pm there were no organised activities observed within the home. Three staff were spoken with all stated that a number of activities take place such as dominoes and card games and that they have an entertainment evening on a Saturday where service users can enjoy music and a drink. A poster was displayed at the home advertising a local musician who had been commissioned to perform at the home. All activities are recorded within an activities file within the home. Four service users were spoken with. One said that he liked reading the paper and another was enjoying reading a magazine. It was pleasing to note the Abbots House DS0000028862.V292816.R01.S.doc Version 5.1 Page 14 positive interaction between staff and service users when discussing items and looking at pictures in the magazines available. In discussions with staff they said that the service users do not have access to daily papers or magazines on a regular basis. It is recommended that this is considered to enable service users to maintain skills and to encourage interaction with staff and one another. Staff said that a small number of service users had recently been on a recent theatre trip. A visiting relative was spoke with she confirmed that her mother had gone on the theatre trip and had enjoyed it. Eight relatives completed a questionnaire prior to the inspection. All stated that they were welcomed into the home at any time. Two relatives were spoken with. One during the inspection and one by telephone both confirmed that staff were friendly and that they were made to feel welcome. One relative commented that meetings with other relatives would be useful to discuss issues relating to the home. This was discussed with the manager. It is recommended that the acting manager explore this idea to ensure that service user’s relatives and representatives are able to express their views about the operation of the home. The acting manager said that a newsletter was going to be sent to relatives to keep them informed about any events or changes within the home. This is a positive development. The cook on duty was spoken with about the food and menu planning within the home. The menu was seen and discussed with the cook. The cook confirmed that service users are offered a choice at all meal times. She stated that they had started to use picture cards to assist the service users to make a choice. A recent CSCI report on the meals offered to service users in care homes entitled Highlight of The Day, which was discussed with the cook. It is recommended that a copy is made available for all staff. During lunch it was observed that one service user did not want the set meal and an alternative was offered. The food within the home was sampled. The meal was braised steak and mushrooms in a red wine sauce with a variety of vegetables. The food quality and the portion sizes were good. A cold drink was offered with the meal. It was observed that a number of service users struggled to eat with the utensils available and that some were unable cut up the portion of meat when this was brought to the attention of staff responded appropriately. It is recommended that care plans include information relating to dietary needs including the utensils and any special requirements needed at meal times. A number of service users who had difficulty using knives, forks and spoons appeared to prefer to use their fingers when eating their meals. Consideration should be given to varying the menu to include finger foods. Dementia research indicates that this is, for some people with dementia, is an easier method of eating. Abbots House DS0000028862.V292816.R01.S.doc Version 5.1 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 The home has a satisfactory complaints system but further work is needed to ensure that relatives and service user know how to raise concerns. The quality in this outcome is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The home has a complaints policy. A pre-inspection questionnaire completed by the acting manager states that there have been no complaints. Eight relatives completed CSCI questionnaires in relation to this inspection. Four stated that they were aware of the complaints procedure and four said they were not. It is acknowledged that it is difficult to display information at Abbots House but the acting manager should consider ways in to ensure this information is available. Abbots House DS0000028862.V292816.R01.S.doc Version 5.1 Page 16 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 & 26 There are outstanding issues in relation to the environment that have been raised by CSCI and the fire authorities, which Stoke on Trent senior management are responding to. The quality in this outcome area is poor. The cleaning and laundry systems within the home provide service users with a clean and hygienic place to live. The quality in this outcome area is good. These judgements have been made using available evidence including a visit to the service. Abbots House DS0000028862.V292816.R01.S.doc Version 5.1 Page 17 EVIDENCE: There are requirements and recommendations regarding the premises made by the Commission for Social Care Inspection (CSCI) and Stoke on Trent fire service, which remain outstanding. Agreed timescales for the completion of the outstanding fire works have now been agreed with the Assistant Director. There are ongoing discussions regarding updating and improving the building. It is recommended that consideration is given to the specific needs of the service user group within Abbots House in the planning process of future improvement with best practice within dementia care informing any decisions. The home is a two-storey property providing all single bedrooms. There is one shared room at the service users’ request. There are four separate living areas, each having a lounge-dining room, with adjacent bedrooms, bathroom and toilets. First floor accommodation is accessed by a shaft lift. Externally there is a car parking area and the rear garden offers an enclosed area for residents. Internally there are appropriate toilet and bathing facilities however, these are not easily identifiable for people with dementia as the door are of a similar design and colour to other doors along the corridor and are therefore indistinguishable. The location of this home ensures that there is a wide range of community facilities nearby that can be readily accessed. The entrance hall has provides a seating area and audio equipment. The communal areas have been tastefully decorated and provide a homely feel. The corridors have been redecorated by the staff and have been completed to a good standard. A number of areas, which have been identified on previous inspections, remain in need of action. A number of window frames were in poor condition and need of replacement. Carpets on the first floor corridor were worn and general décor in parts of the building require updating. The service user bedrooms that were seen were not ‘homely’ with little evidence that they had been personalised. The laundry area was examined and a member of staff was spoken with about laundry procedures. The laundry was well organised and the staff member was knowledgeable about her role and keen to listen to suggestions regarding good practice. The home have developed a book to record and items of clothing which are spoiled and the service user is reimbursed. This is transparent practice and reduces the risk of disagreements with service users or relatives. Protective clothing was available. It is recommended that a colour coding system is in place for mops and buckets to reduce the risk of cross infection. Abbots House DS0000028862.V292816.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 The staffing complement and NVQ training within this home provides satisfactory levels of competent staff to meet the needs of the service users. Ongoing staff training in adult protection would increase the skills of the staff to further ensure that service users were protected from potential harm. The quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. EVIDENCE: On the day of the inspection there were 33 service users resident at Abbots House. There were two assistant managers; four care staff and one care staff member having an induction. There were two staff in the kitchen, two domestic staff and one laundry assistant. There was adequate staff on shift to meet the needs of the service users. There have been some staffing difficulties due to staff sickness within this home over the past three months. The acting manager has managed these difficulties in a professional manner and has sought, where possible, to ensure consistency of care by using the same bank and agency staff. Rotas and staffing records indicate that a number of staff have now returned to work with less reliance on agency and bank staff. The pre inspection questionnaire completed by the manager indicates that 77 of staff have received NVQ2 or above training. During the inspection three care staff, one laundry assistant, a cook, kitchen assistant and the acting manager were spoken with and training and recruitment records for four staff were also examined. Staff stated that they had received training in their Abbots House DS0000028862.V292816.R01.S.doc Version 5.1 Page 19 respective areas of work. Three staff were asked about vulnerable adults training. Staff stated that this was covered during NVQ training. It is the inspectors understanding that the information covered on this course does not provide staff with adequate skills and knowledge regarding identifying and reporting abuse. The need for training is further reinforced by discussions with staff in relation to a recent vulnerable adult investigation. Staff training certificates stored within staff personnel files confirmed that a range of training has taken place. Four staff files were examined in relation to vetting and recruitment. There is an equal opportunities policy in place. All files contained satisfactory evidence that appropriate vetting had taken place prior to employment. This is good practice and ensures that service users are protected from potential harm. Abbots House DS0000028862.V292816.R01.S.doc Version 5.1 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35 & 38 The acting manager is qualified to run the home and is respected by staff. Quality assurance systems in the form of questionnaires are in place, however the resulting outcomes for service users are not evident. The overall quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: There is a an acting manager in place within this home who has over 17 years experience in working with older people. She has been in post for three months. The acting manager has worked in a variety of management positions since 1996, which has included a secondment to a service coordinator post. The acting manager has the appropriate management qualifications. The feedback from staff regarding the present management style within the home was very positive and supportive. One staff member said ‘she listens to Abbots House DS0000028862.V292816.R01.S.doc Version 5.1 Page 21 staff and asks them what they think. Staff feel they can go to her with anything’. It was noted that since moving into post the acting manager had implemented a range of systems, which were service user focused and which provided transparency about the way in which the home operates. Quality assurance systems were discussed with the acting manager who stated that this work was ‘ongoing’. She advised that she was looking at ways in which they could measure the results of quality assurance information to then improve the outcomes for service users. This remains an ongoing requirement. The way in which the home handles service user’s monies was inspected in August 2005 and found to be satisfactory. There was evidence of good recording accompanied by receipts, which provided a clear audit trail of monies spent. Any monies taken from a service user’s personal allowance was shown to have two staff signatures with service users also signing for their money if they are able to. A record is also kept of any valuables handed over for safekeeping. Fire records were examined. There was evidence that regular fire drills take place. The fire risk assessment was dated 20. This must be reviewed. Three staff members were asked about fire procedures and drills. All confirmed that fire drills take place and all had an understanding of what to do in the event of a fire. The staff spoken with also stated that they had received the appropriate fire and health and safety training. The pre inspection questionnaire completed by the acting manager states that 20 staff have a current first aid certificate. An assistant manager confirmed that there is always a member of staff on shift who is qualified in first aid. Legionella checks are made. There was evidence that all accidents are recorded however, issues in relation to data protection were noted. A recommendation was made at the last inspection this will remain. Abbots House DS0000028862.V292816.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 2 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 x 1 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 3 2 3 3 x x 3 Abbots House DS0000028862.V292816.R01.S.doc Version 5.1 Page 23 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 OP2 Regulation 5(1b)(c3) Requirement All service users to have a contract (Previous timescale of 06/03/05 and 30/10/05, 31/03/05 not met) In consultation with the fire officer fit suitable locks to the bedroom doors (Previous timescale of 06/02/05, 31/03/06 not met) The outstanding recommendations made by Staffordshire Fire and Rescue to be addressed in timescales agreed with them or by. The manager must demonstrate how service users wishes and feelings have been taken into account regarding limited access to their bedrooms.(Previous timescale of 31/03/06 not met) The manager must demonstrate how the arrangements regarding the limited access to bedrooms by service users, is recorded DS0000028862.V292816.R01.S.doc Timescale for action 30/06/06 2. OP24 13(4) 31/05/06 3. OP38 23(4)(a) (b) 31/05/06 4. OP10 12(3) 30/06/06 5. OP10 5(10)(b) 30/06/06 Abbots House Version 5.1 Page 24 within the statement of purpose and service user guide.(Previous timescale of 31/03/06 not met) 6 7 8 OP18 OP3 OP7 18(1)©(i) 14(1)(a) 15(1) All staff must receive vulnerable adult training. All service users must have a care management assessment in place prior to admission. All care plans must be comprehensive which details how a service users needs in respect of his health and welfare are to be met. Individual risk assessments must be in place in relation to identified areas of risk. Weight must be regularly recorded and monitored. Gloves used to assist service users with their personal care needs must discarded after single use. Quality assurance systems and quality monitoring systems must be fully implemented. 31/08/06 31/05/06 30/06/06 9 10 11 OP7 OP7 OP10 13(4)© 12(10(a) 13(4)© 31/05/06 31/05/06 31/05/06 12 OP33 24(1) 31/08/06 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. 2. 3. Refer to Standard OP29 OP7 OP33 Good Practice Recommendations The Department of Health POVA guidance should be available to all senior staff. Staff should receive care-planning training when the new care plan system is introduced. Any change in service as a result of the feedback from service users, relatives or professionals should be recorded. DS0000028862.V292816.R01.S.doc Version 5.1 Page 25 Abbots House 4. 5. 6. 7 8 9 10 11 12 13 14 15 16 OP33 OP28 OP12 OP38 OP13 OP8 OP12 OP7 OP15 OP15 OP13 OP26 OP19 A copy of the inspection report should be displayed and available to staff, service users and relatives. Induction records should be signed and dated by supervisor and staff member when induction completed. The manager should consider how information regarding activities is made available to service users. Accident recording should comply with data protection. The manager should consider ways to improve systems to inform relatives of events such as hospital visits. The manager should consider ways in which the smell of cigarette smoke within the home can be reduced. The manager should consider purchasing daily papers/magazines for service users. Care plans should include information about what utensils a service user needs at meal times and other requirements. The CSCI report Highlight of the Day should be made available to all staff including kitchen staff. Consideration should be given to including finger foods on the menu as good practice guidance for dementia care. Consideration should be given to meeting with relatives to consider ways of further improving the home. A poster which states the colour coding for mops and buckets should be displayed within the laundry and domestic storage areas. Any future planning regarding the building should be informed by up-to-date information on best practice in dementia care. Abbots House DS0000028862.V292816.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 House DS0000028862.V292816.R01.S.doc Version 5.1 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!