Inspection on 18/04/08 for Abbotsfield Hall Nursing Home

This inspection was carried out on 18th April 2008.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Abbotsfield Hall Nursing Home 06/06/07

Abbotsfield Hall Nursing Home 08/06/06

Abbotsfield Hall Nursing Home 21/02/06

Abbotsfield Hall Nursing Home 16/08/05

Abbotsfield Hall Nursing Home 18/01/05

Abbotsfield Hall Nursing Home 13/07/04

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

CARE HOMES FOR OLDER PEOPLE Abbotsfield Hall Nursing Home Abbotsfield Tavistock Devon PL19 8EZ Lead Inspector Anita Sutcliffe Unannounced Inspection 18th April 2008 13:45 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 Abbotsfield Hall Nursing Home DS0000003572.V361213.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. Abbotsfield Hall Nursing Home DS0000003572.V361213.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbotsfield Hall Nursing Home Address Abbotsfield Tavistock Devon PL19 8EZ 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) 01822 613973 01822 617260 Mr Eamon Charles Gaffney Mrs Hazel Gaffney, Mrs Pamela Watson, Mr Graham Watson Mrs Pamela Watson Mrs Hazel Gaffney Care Home 28 Category(ies) of Old age, not falling within any other category registration, with number (28), Physical disability over 65 years of age of places (28) Abbotsfield Hall Nursing Home DS0000003572.V361213.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Service Users aged 65 years and over PD(E) Maximum registered 28 service users (both) OP Maximum registered 28 service users (both) Date of last inspection Brief Description of the Service: Abbotsfield Hall is situated on the outskirts of Tavistock. It is owned and managed by Mr and Mrs Gaffney and Mr & Mrs Watson. There is 24 hour trained nurse cover supported by a team of carers and ancillary staff. The home provides nursing and personal care for up to 28 older people of either gender. The home is arranged on 2 floors with a passenger lift and stair lift available. There are 16 single and 6 double bedrooms; a few bedrooms on the first floor do not have level access. The ground floor has two lounges and a dining room. It is well adapted in order to meet the needs of the residents. There is a large accessible garden. Information about the home, including a copy of the last inspection report, is available in the entrance hall. Information given to the Commission by the provider indicates the current range of fees is from £480 to £530 a week. Additional charges are made for chiropody, hairdressing, newspapers and toiletries. Abbotsfield Hall Nursing Home DS0000003572.V361213.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. Information about the home has been collected towards this inspection since June 2007. This key inspection included two unannounced visits. As part of the visits we looked at all communal areas, and most bedrooms. We spoke with several people who use the service, some family and observed staff going about their work. We looked at the care and support that three people received, meeting them and looking at their care records. We saw and spoke with others. We spoke with the registered owners and eight staff. We also looked at some records at the home. People who use the service may be described within this report as residents, clients or service users. What the service does well: People who use the service receive an excellent level of nursing and personal care. Comments from family included: “Fabulous care. Second to none” and “Excellent care”. The staff are experienced and demonstrate a high degree of knowledge and skill. People who use the service benefit from a stable staff team with many of the staff having been employed for a number of years. One who has worked at the home for sixteen years said: “Staff stay because it’s very much a family place”. There were several references to the home being a ‘family’ environment. The feedback about food was positive: “very good”, “plenty”, people confirming that it was enjoyed and in sufficient quantity. People are happy with the visiting arrangements. Visitors said they feel welcomed into the home and are able to visit their relative/friend in private or socially. The home environment is warm, clean and appeared to be comfortable. Abbotsfield Hall Nursing Home DS0000003572.V361213.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Each person, prior to admission, or at that point, must receive written confirmation that their assessed needs can be met by the home. This is part of the contract between them, protecting both the person and the home. The homes policies and procedures on the handling of medicines must be reviewed, taking into account guidelines and current legislation, which protect people from mistakes and possible mishandling of medicines. The home’s management of medicines is currently unsafe. Peoples’ social, cultural and recreational interests should be assessed, recorded and be part of the care planning process. When the home recruits new staff they must not start employment until all required safety checks are completed. This includes two written references and criminal record check. This protects people from staff who may be unsuitable to care for them. The home’s quality review arrangements should take into account all stakeholders in the service, including staff. Risks must be assessed and managed so that people who use the service are protected from unnecessary risk. This includes freestanding, unsteady wardrobes, which would fall if pulled, the risk from Legionella, and the risk from the use of bed-rails. The home must also provide evidence that the washing machines in use meet the necessary criteria for a home providing nursing. Abbotsfield Hall Nursing Home DS0000003572.V361213.R01.S.doc Version 5.2 Page 7 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. Abbotsfield Hall Nursing Home DS0000003572.V361213.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 Abbotsfield Hall Nursing Home DS0000003572.V361213.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): 3 (Standard 6 does not apply to Abbottsfield Hall) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s diverse needs are identified and planned for before they move to the home. EVIDENCE: We saw the home’s admission procedure which outlines how the home can assist people to make the move to a care home as smoothly as possible. We examined the care of a person recently admitted to the home. Her needs had been fully assessed prior to admission and included copies of assessments carried out through care management arrangements and hospital/community health care teams. The home uses a standard assessment form; this assesses people’s needs in depth and allows the lead nurse to make a decision about whether or not these needs can be met. Abbotsfield Hall Nursing Home DS0000003572.V361213.R01.S.doc Version 5.2 Page 10 We were told that each person receives a contract or statement of terms and conditions. However, at present people who will be admitted do not receive confirmation in writing that, having assessed their needs, the home is both suitable for them and able to meet those needs. This confirmation protects both the person and the home should problems arise. We spoke with several people who live at the home. All were complimentary about the care they receive and the friendliness of staff. Abbotsfield Hall Nursing Home DS0000003572.V361213.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): 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. People who use the service can be assured of an excellent standard of health and person care but not that the handling of medicines is properly safe. EVIDENCE: Plans are required to be clear so that staff can look after people in the correct way, and as they wish, once their needs have been assessed. We looked at the plans for three people who receive the service at Abbottsfield Hall. We found the format the home uses for care planning made finding important information somewhat difficult. However, staff were fully able to describe people’s needs and how they are to be met. The providers said they intend to change the format for the care plans so that information is more readily available. Abbotsfield Hall Nursing Home DS0000003572.V361213.R01.S.doc Version 5.2 Page 12 Each plan seen was very detailed in the ongoing assessment of all needs – health, emotional and social – and provided good evidence that those needs were being met. Examples of this include contact with other health care providers such as physiotherapist, community psychiatric nurse, district nurse team and doctors. We also read the daily record of people’s care from which it was clear that trained staff themselves have the knowledge and skill to ensure people receive appropriate health care. We looked at the way the home manages medicines. We were told there has never been a medicine error. However, for a second visit we saw that medicines for more than one person were being pre potted and carried on a tray. We saw that these medicines were transported from the medicines trolley to the lounge or dinning room in unlidded pots. This can pose a danger of spillage and loss if the member of staff were to trip. The use of a tray to transport a number of medicines to different people increases the risk of people receiving medication that is not prescribed specifically for them. The signing of medication records on mass after administering to a number of people increases the risk that records may not be accurate as the staff member has to remember who may have refused or been unable to take their medication at the time they were administering from the tray. We saw medicines left unattended in the dining room and unlocked office, where people could easily take them. We also saw the keys to all medicine storage left unattended on the office desk and people entering the building pass the open office door. This leaves the medicines open to mishandling. The home has good systems in place to ensure medicines are ordered, received and disposed of properly and the medicine records examined were orderly and complete. People spoken with confirmed staff are polite and friendly and treat them with respect. Our observation supported this. Where one person has behaved in an unacceptable way toward staff those staff have been helped to understand the behaviour and use coping methods. Those methods were part of the planned care. Where people share rooms there are screens available and each person is able to lock their door for privacy should they wish. Family of a person who uses the service said: “Staff are always kind and respectful”. Abbotsfield Hall Nursing Home DS0000003572.V361213.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use this service enjoy a peaceful, pleasant life and good standard of food. EVIDENCE: We saw people sitting in the lounges, some reading. None stayed in their own room unless very unwell. At the last key inspection staff were seen enabling people to engage in meaningful conversation, but we did not see staff spending one to one time with people over our two visits unless involved in a task, such as taking them to the visiting dentist. (See also Standard 27). The plans of care we saw contained some information about family and social history but this was quite limited. The providers said they have started ‘personal profiles’ so that information of importance will be available to staff, for example, important dates, activities of interest, preferences and choices. They said this would be included in the new format for care planning. One family member said the only improvement she felt the home could make was Abbotsfield Hall Nursing Home DS0000003572.V361213.R01.S.doc Version 5.2 Page 14 to: “Help people to go out, or have some movement or exercise”. However, staff felt most people were too frail; most of those seen were extremely frail. During our visit an entertainer visited the home and people were clearly enjoying the songs and music. We saw from records that there had recently been a ‘clothes show’ and sale. We saw people taken out by family. The gardens have level access so wheelchair access is easy. They are also nicely kept and pleasant and can be viewed from communal rooms at the home. At the time of our visit all the people using the service were of British origin and white. They were predominantly of a Christian faith and we saw that Communion had been arranged for one. The feedback about food was positive: “very good”, “plenty”, people confirming that it was enjoyed and in sufficient quantity. The meal on the first visit, being a Friday, was fish and chips and the second visit was a roast. The menu for the day is written on a notice board and staff confirmed that the cook speaks with people to ensure they will want what is planned. We saw the two week menu plan. It was quite varied including salad and pasta meals. We were told that at the week end people have a sherry and if they choose to have alcohol regularly this is arranged where ever possible and medically safe. Where specialist diets are necessary this is provided and staff are aware of the importance of diet where people are very frail and needing specialist arrangements. The people living in the home said they were happy with the visiting arrangements, visitors said they feel welcomed into the home and are able to visit their relative/friend in private or socially. Abbotsfield Hall Nursing Home DS0000003572.V361213.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People at the home are protected by the accessibility of the staff and providers and the home’s policies and procedures. EVIDENCE: There is a complaints procedure displayed in the entrance hall and within the guide about services. It was clear from observation that people who used the service and their family/visitors felt comfortable discussing issues with the staff and managers. The record of concerns and complaints showed that there had been no entries since 2003. When this was discussed we were told that any issues raised were dealt with promptly and did not lead to a complaint. There have been no complaints referred to the Commission about this service. We asked staff about how they would protect people from abuse. They were able to describe types of abuse and the actions they would take if they had concerns. The homes policy and procedures for safeguarding adults is readily available to staff. However, the contact details for the complaints procedure and the whistle blowing procedure (how to make concerns known outside the home Abbotsfield Hall Nursing Home DS0000003572.V361213.R01.S.doc Version 5.2 Page 16 should it be necessary) were out of date. The providers said this would be corrected immediately. Staff have received some training in how to manage difficult behaviours, abusive in nature, from people who use the service and directed at them. They felt that this had been very useful, helping them to understand why it should occur and how to respond if it does. Abbotsfield Hall Nursing Home DS0000003572.V361213.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People live in a home which is clean, fresh, homely and well equipped, but where safety is not fully managed. EVIDENCE: We visited all shared areas of the home and most bedrooms, the laundry and kitchen. We were impressed by the cleanliness throughout, and the warmth in all areas of the home on what was a very cold day. Bedrooms were very personalised and homely and each person had a key to the room hung just in side so that the door could be locked when leaving if they wished. Each room had hand washing facilities for staff, to reduce the likelihood of cross infection. Staff have protective clothing available to them Abbotsfield Hall Nursing Home DS0000003572.V361213.R01.S.doc Version 5.2 Page 18 for the same reason and have received training /updates about how to prevent and control infection. The laundry was clean and contained sufficient amounts laundry equipment. However, the providers could not confirm that it met current legislation, which would ensure that what was used was suitable to meet the needs of a nursing home, which needs to manage soiled laundry. We visited several rooms which contained free standing wardrobes. These might fall on people if they pull on them, perhaps if they have fallen and are trying to get up. These need to be made safe. We also found first floor windows which opened wide and posed a risk from falls. These had been made safe by the second inspection visit. Staff said they had all necessary equipment needed, for example to help immobile people with movement, and equipment did appear to be well provided. Communal rooms are large and full of character. People said they liked them. Paint work was being ‘freshened up’ during both visits and were told this will continue throughout the entire building. We were also told of plans to renew carpets. Abbotsfield Hall Nursing Home DS0000003572.V361213.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff at the home are well trained and supported, and employed in sufficient numbers to meet peoples’ physical needs, but not recruited in a safe way. EVIDENCE: People who use the service benefit from a stable staff team with many of the staff having been employed for a number of years. One who has worked at the home for sixteen years said: “Staff stay because it’s very much a family place”. We spoke with five care staff and one trained staff. Those who only work mornings felt that there were sufficient staff on duty to meet people’s needs, but those who work afternoons were adamant that staff numbers were insufficient. They said they no longer had time to spend with people, only move from task to task. One added: “It feels like a conveyor belt in here”. We found that staff were not spending one to one time with people as they did during the last key inspection of the home. For people who are so frail that they can only participate as passive observers of activities – for example, they may be unable to read themselves or take trips away from the home – this is a big disadvantage. They are at risk of becoming socially isolated. Abbotsfield Hall Nursing Home DS0000003572.V361213.R01.S.doc Version 5.2 Page 20 Staff described the various training they have had, mostly that which is mandatory and concerns health and safety, such as infection control. People who use the service and their family felt that staff were very competent and skilled. The home’s providers talked of difficulties in getting staff to attend training, a recent training event on types of eyesight problems was poorly attended. We examined the recruitment records of the last two people recruited to work at the home. One was a domestic worker and one was a trained nurse. Neither had been properly checked to see if they had a criminal record or were on the list of people unsuitable to work with vulnerable adults, prior to employment. One only had one written reference and not the two required. One of the providers felt sure these were isolated cases but it remains an unsafe situation which we have raised as a requirement in the past at the home. Abbotsfield Hall Nursing Home DS0000003572.V361213.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 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. People who use the service benefit from an experienced management that is committed to a high standard of care, but their approach to safety puts people at unnecessary risk. EVIDENCE: The home is owned and run by two married couples the wives are both registered nurses and share the responsibilities of the position of Registered Manager between them. Both have obtained the Registered Managers Award. We saw that there was relaxed communication between the manager on duty and the people who use the service, staff and people who visited. Staff talked Abbotsfield Hall Nursing Home DS0000003572.V361213.R01.S.doc Version 5.2 Page 22 of how supportive the providers/managers are with issues that affect their lives and ability to work. Comments about the management team from people we spoke to who use this service were also complimentary. People told us that all of the managers are accessible and approachable, friendly and efficient. We looked at how the home makes judgements about the quality of the service that is provided. We were told that surveys are sent yearly to people who use the service, their family and staff. We were therefore surprised when staff said they are not included in the survey results; they do not know what people say about the service they provide. Five staff said that the point they had raised through survey, regarding their belief there was a need for more afternoon staff, had not been discussed with them. Staff were asked if they have staff meetings; they said no. Although they meet frequently for a handover of information regarding people’s needs, meetings offer them the opportunity to bring non-care related issues to discuss which may affect the standard of service provided. Asked about one to one supervision we were told there is twice yearly staff appraisal, whilst six weekly is recommended as the minimum standard. Staff do not have sufficient opportunity to be involved in the quality of the service they provide. Policies and procedures are in place and available for to inform staff what is expected of them, for example, how a person is to be admitted to the home. Although some previous requirements have now been met we found continuing problems with safe handling of medication and, where recruitment had been safe at the last inspection, it was again unsafe as had been found previous to that. The home keeps an allowance for some people who use the service. This is kept securely with records double signed and a clear balance of money remaining. We saw records that show hot water is being stored at 52 degrees whilst it must be stored at 60 degrees to remove the risk from Legionella infection. We also found a risk from free standing wardrobes (see Standard 19), which could fall if pulled. We found no assessment of risk where people have bed-sides in situ. This can cause entrapment if risk is not properly assessed and managed. However, there have been no accidents at the home to date. Abbotsfield Hall Nursing Home DS0000003572.V361213.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Abbotsfield Hall Nursing Home DS0000003572.V361213.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No 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 OP3 Regulation 14(1)(d) Requirement Timescale for action 30/04/08 2. OP9 13 (2) 3. OP19 13 (4) 4. OP26 13(3) The registered person must confirm in writing that, having assessed their needs, the home is able to meet those needs and is suitable for them. This protects both the person and the home and is a legal requirement. 30/04/08 People’s medicines must not be dispensed into a tray of unlidded pots, even though named, prior to administration. They should be administered directly from the dispensed container to the person. Neither must medicines, or the keys to medicines storage, be left unattended. These measures will reduce the likelihood of mistakes or mishandling. People must be protected from 16/05/08 hazards to their health and safety, in this case unstable, freestanding wardrobes which would fall on them if pulled. The providers must confirm to us 15/06/08 (CSCI) in writing that the laundry equipment in use is able to wash foul laundry (minimum 65 degrees) for not less than 10 DS0000003572.V361213.R01.S.doc Version 5.2 Abbotsfield Hall Nursing Home Page 25 5. OP29 19 6. OP38 13 (4) 7. OP38 13 minutes, that washing machines have the specified programme ability to meet disinfection standards and services and facilities at the home comply with the Water Supply (Water Fittings) Regulations 1999. This is to ensure that people are properly protected from cross infection at the home. The registered person must not 18/04/08 employ a person to work at the care home unless all the required checks - paragraphs 1 to 9 of Schedule 2 of the care home regulations - have been completed so the home can be sure the person does not have a criminal record and is safe to work with vulnerable adults. This was been a previous requirement at the home. All potential risk to people who 16/05/08 use the service must be assessed, including the use of bed-sides. The systems in place to protect 30/06/08 people from the risk of Legionella must be reviewed, taking into account professional guidance, to ensure that the home is managing this hazard correctly. The home must inform us of their findings and actions that have been taken. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP12 Good Practice Recommendations To ensure the lifestyle in the home matches the DS0000003572.V361213.R01.S.doc Version 5.2 Page 26 Abbotsfield Hall Nursing Home 2. OP33 expectations of those people living in the home people should have their social, cultural and recreational interests recorded including a plan on how to meet them. This good practice recommendation has been repeated. Staff opinion should be included in the arrangements for assessing the quality of the service provided. Abbotsfield Hall Nursing Home DS0000003572.V361213.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Abbotsfield Hall Nursing Home DS0000003572.V361213.R01.S.doc Version 5.2 Page 28 - 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!