Inspection on 06/06/07 for Abbotsfield Hall Nursing Home

This inspection was carried out on 6th June 2007.

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

Abbotsfield Hall Nursing Home 18/04/08

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 Fiona Cartlidge Unannounced Inspection 6th June 2007 10:50a 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.V331314.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.V331314.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.V331314.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 8th June 2006 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/week. Additional charges are made for chiropody, hairdressing, newspapers and toiletries. Abbotsfield Hall Nursing Home DS0000003572.V331314.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The site visit took place over 4 hours and was unannounced. A partial tour of the home took place when some bedrooms and all communal areas were viewed. Three residents had their care case tracked this means their records were examined in detail and these residents were spoken to in depth about the care and services they receive. Five other residents were spoken with during the visit, as were one visitor/relative, three members of staff, one of the managers and one other person on behalf of the 4 registered providers. Personnel records of 3 members of staff and policies and procedures were also inspected. Eight visiting health care Professionals and 4 members of the homes care staff retuned surveys. What the service does well: Those considering using this home have sufficient information about the home in order to make an informed decision about whether the service is right for them. The personalised needs assessment means that people’s diverse needs are identified and planned for before they move to the home. People told us that they chose this home because of the friendly supportiveness of the staff and the proximity of the home and because of its calm but cheerful atmosphere. They confirmed that the home had done an excellent job in meeting their needs. People who use this service are provided with a good level of health and personal care. 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. Generally the environment is satisfactory the décor and furnishings are homely; All of the Residents spoken to were satisfied with their private accommodation and there was evidence that they are able to bring personal Abbotsfield Hall Nursing Home DS0000003572.V331314.R01.S.doc Version 5.2 Page 6 items with them into the home. The lounges and dining room are all on the ground floor and are large, light and airy, the large windows provide ample cool ventilation on warm days. Staff at the home are well trained and supported, and employed in sufficient numbers to meet the service users’ needs at all times. The residents were extremely complimentary about the staff, confirming their needs were met 24 hours a day. Comments received included: ‘I am really impressed with the care and support that I am given here at Abbotsfield Hall’, ‘the staff are kind and attentive’, ‘as soon as you ask the staff for something you get it’. This home has a strong and competent management team and there are clear lines of accountability. Comments received from staff on surveys returned to us included: ‘ our managers work with us as part of the team, we have meetings daily at handovers and we are encouraged to bring up any problems’. The home is a great place to work because the managers are very understanding’. 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. What has improved since the last inspection? We performed a tour of the home and found that improvements had been made to the environment since our last visit to the home: In order to promote Fire safety we found that more doors to residents’ bedrooms had been fitted with ‘safe’ hold open devices. To ensure the privacy, dignity and security of residents, doors to individuals’ bedrooms have been fitted with locks. People who use this service now have the opportunity to have a shower or a bath because a level access shower has been installed. People who work in the home have had their safety improved through provision of non- slip flooring in the kitchen. Internal quality assurance processes have been formalised; Surveys have recently been sent to residents and staff these are being returned and will provide information for the managers to analyse and use to plan future improvements. A number of appreciation cards were seen from grateful relatives of people who have used this service. Policies and procedures within the home are in place and have recently been reviewed. Action has been progressed to implement requirements identified in our previous inspection report. Abbotsfield Hall Nursing Home DS0000003572.V331314.R01.S.doc Version 5.2 Page 7 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 Abbotsfield Hall Nursing Home DS0000003572.V331314.R01.S.doc Version 5.2 Page 8 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.V331314.R01.S.doc Version 5.2 Page 9 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.V331314.R01.S.doc Version 5.2 Page 10 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): 1,3,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service have sufficient information about the home in order to make an informed decision about whether the service is right for them. The personalised needs assessment means that people’s diverse needs are identified and planned for before they move to the home. EVIDENCE: The home has a statement of purpose this document sets out the aims and objectives of the home and provides detailed information about the service. This and a simpler guide were available for inspection and can be found in the entrance hall of the home copies can be requested from the homes administration office. Abbotsfield Hall Nursing Home DS0000003572.V331314.R01.S.doc Version 5.2 Page 11 The personal records of 3 Residents were seen in detail and these Residents were then spoken with about their experience of living at Abbotsfield Hall these Residents confirmed that the home was meeting the expectations they had when they were admitted. One Service User said that their family had visited and chosen the home because they themselves had been too poorly. This resident’s son confirmed they had chosen the home for two main reasons; The friendly supportiveness of the staff and the proximity of the home. Another told us as soon as they came into the home to look around they new ‘this was the place’ because of its calm but cheerful atmosphere. Both confirmed that the home had done an excellent job in meeting their needs. An assessment of care needs of prospective Residents takes place prior to admission to the home. Documents seen provided evidence that the home uses a standard assessment form; this assesses prospective Residents needs in depth and allows the homes personnel to make a clear decision about whether or not these needs can be met. Other records seen included copies of assessments carried out through care management arrangements and hospital/community health care teams where applicable. Abbotsfield Hall Nursing Home DS0000003572.V331314.R01.S.doc Version 5.2 Page 12 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 this service are provided with a good level of health and personal care but they are not fully protected by the homes policies and procedures for medicines. EVIDENCE: Residents spoken with confirmed they receive a good level of care. Personal records held on behalf of 3 Residents were examined; in all of those seen there were documented assessments which provided information about skin integrity, moving and handling, safety - including risk of falls and nutritional screening. The information generates the plans of care, which provide the basis for the care to be delivered. The plans of care are held in the nurses office, resident’s spoken to in detail were aware of the documentation held on their behalf. Abbotsfield Hall Nursing Home DS0000003572.V331314.R01.S.doc Version 5.2 Page 13 All of the plans had been regularly reviewed and updated to reflect changing needs; this is good practise because Staff use these records to inform them about how to meet peoples care needs. If they contain up to date information peoples needs should be consistently met. Records are maintained for all visits to the home by social or health care professionals, all Residents are registered with a GP. Records provided evidence that as well as visits from General Practitioners, specialist nurses and chiropodists visit. Records of outpatient appointments show that visits to community and hospital health resources are enabled. Written information was received via survey forms that were returned to the Commission by 8 visiting health care professionals. These indicated that the home communicates clearly and works in partnership with them and that they are satisfied with the overall care provided to Residents within the home. One general practitioner commented ‘ the staff appear caring, senior staff and matron especially so, an excellent home’. We found that some hand written entries on the Medicine Administration Record (MAR) charts indicated that the person was receiving a 100 times overdose. The qualified staff on duty at the time had not noticed the error in the recorded dose. We saw medicines for more than one person being pre potted and carried on a tray. We saw that these medicines were transported from the medicines trolley in the nurses’ office to the people’s rooms, lounges 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 residents increases the risk of residents receiving medication that is not prescribed specifically for them. The signing of medication records on mass after administering to a number of residents 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 looked at the records of medications ordered and procured and found a commendable practise in place where staff record the date the medication has been opened for the first time, this good practise allows for regular auditing of medications given and minimises the risk of medications being misused. Abbotsfield Hall Nursing Home DS0000003572.V331314.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service enjoy a peaceful, pleasant yet varied life, with family and local community links maintained and encouraged. Various formal and informal impromptu activities are made available on a regular basis. Good quality meals are provided. EVIDENCE: During the site visit, some residents were seen sitting in the lounges. Other residents were seen spending time in their own rooms, reading, listening to music, or watching television. Staff were seen encouraging and enabling residents to engage in meaningful conversation. Abbotsfield Hall Nursing Home DS0000003572.V331314.R01.S.doc Version 5.2 Page 15 Two of the three records seen did not contain information about people’s life experiences their interests or hobbies. Organised activities are arranged on some days and these are communicated verbally by the staff to the residents. There were no organised activities on the day of our visit but residents spoke of their enjoyment when a tractor show had been arranged in the homes ground on the previous weekend. At the time of our visit all the residents living in the home were of British origin and white. They were predominantly of a Christian faith. The feedback about food was positive all of the residents spoken with said how good it was; twelve residents ate lunch in the dining room those requiring assistance where provided with this in the sitting room/lounge others ate their lunch in their own accommodation. The food served at lunchtime looked and smelt appealing most people had roast beef with vegetables, potatoes and Yorkshire pudding followed by peaches and ice creams. Alternatives to the main meal at lunchtime were not advertised (a black board in the dining room displays the menu for the day) but residents told us that the staff know their likes and dislikes and do not give them food they do not like, alternatives are arranged. 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.V331314.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements for protecting people who use this service and responding to their concerns are satisfactory. EVIDENCE: This service has a complaints procedure it is clearly displayed in the entrance hall and was seen advertised in the guide about services. Residents and visitors confirmed that they felt comfortable discussing issues with the staff and managers. A record of concerns and complaints was available for inspection there had been no entries since 2003. There have been no complaints referred to the Commission about this service. Records seen show that the Staff are made aware of and attend training on the recognition and reporting of incidents or allegations of abuse or neglect, all 4 staff who returned surveys to us indicated they are aware of adult protection procedures. The homes policy and procedures for safeguarding adults gives clear specific guidance. The local authority procedures were also seen in the entrance hall meaning they were accessible to both staff and visitors to the home. Residents said they feel safe living in the home. Abbotsfield Hall Nursing Home DS0000003572.V331314.R01.S.doc Version 5.2 Page 17 Abbotsfield Hall Nursing Home DS0000003572.V331314.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Generally the environment is satisfactory the décor and furnishings are homely; there are areas of the home that would benefit from improvement. EVIDENCE: We performed a tour of the home and found that some improvements had been made to the environment since the last visit to the home. We found that more doors to residents’ bedrooms had been fitted with ‘safe’ hold open devices. In order to promote the privacy, dignity and security of residents, doors to individuals’ bedrooms have been fitted with locks. Abbotsfield Hall Nursing Home DS0000003572.V331314.R01.S.doc Version 5.2 Page 19 Some areas of the home are still in need of improvement some bedrooms need re-carpeting and decorating some of the furnishings look old and worn and some non - adjustable beds are still in use. People who use this service now have the opportunity to have a shower or a bath because a level access shower has been installed. People who work in the home have had their safety improved through provision of non- slip flooring in the kitchen; a new gas cooker has also been installed. The lounges and dining room are all on the ground floor and are large, light and airy the large windows provide ample cool ventilation on warm days. The inspector found a range of equipment around the home, available to assist staff in moving and handling residents, as well as a disinfecting sluice, hand washing facilities and disposable gloves and alcohol rubs for use when/if in contact with body fluids. All of the Residents spoken to were satisfied with their private accommodation and there was evidence that they are able to bring personal items with them into the home. A tub of skin cream was found in a communal bathroom the tub (petroleum gel) did not contain the identity of the resident it was to be used for this is poor infection control practise. Two bathrooms were seen to have soap bars in them this poses a risk that soaps may be ‘shared’ increasing the risk of cross contamination/infection. The environment was clean and odour free. Records show that all equipment and systems are regularly serviced. Abbotsfield Hall Nursing Home DS0000003572.V331314.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff at the home are well trained and supported, and employed in sufficient numbers to meet the service users’ needs at all times. EVIDENCE: This home benefits from a stable staff team with many of the staff having been employed for a number of years. Three Personnel files were examined, these records showed a commitment to safe recruitment practises, files contained detailed application forms, two written references and proof of identity. For recently employed Registered Nurses their was evidence that they had, had their qualifications checked with their regulatory authority. There was evidence of Criminal Record Bureaux checks these had been transferred (against current guidance), the registered manager confirmed this practise only happens when individuals have had a very recent CRB check performed (within weeks). Training and development records provided evidence that training is provided and ongoing. 4 Staff who returned surveys to us indicated they receive sufficient training to enable them to meet the needs of those living in the home. Abbotsfield Hall Nursing Home DS0000003572.V331314.R01.S.doc Version 5.2 Page 21 Comments received on staff surveys returned to both us and internally within the home included: ‘would like more staff on each shift, as the staff and residents would both benefit’. ‘ A lot of our residents and visitors comment on how like home it is and the staff are always friendly, we are always laughing and joking with residents and visitors, like one big family’. Residents and visitors throughout our visit to the home echoed these comments. Information provided in the pre-inspection questionnaire suggests that 15 care staff (82 ) have obtained a National Vocational Qualification (NVQ) in care at level 2 or above. The residents were extremely complimentary about the staff team confirming their needs were met 24 hours a day. Comments received from clients included: ‘I am really impressed with the care and support that I am given here at Abbotsfield Hall’, ‘the staff are kind and attentive’, ‘as soon as you ask the staff for something you get it’. Abbotsfield Hall Nursing Home DS0000003572.V331314.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Abbotsfield Hall is managed well and run in a safe way, which also takes into account the best interests of service users. EVIDENCE: This home has a strong and competent management team and there are clear lines of accountability. 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. Abbotsfield Hall Nursing Home DS0000003572.V331314.R01.S.doc Version 5.2 Page 23 The inspector witnessed a good level of communication between the manager on duty and the staff residents, visitors/relatives and visiting professionals. Comments received from staff on surveys returned to us included: ‘ our managers work with us as part of the team, we have meetings daily at handovers and we are encouraged to bring up any problems’. The home is a great place to work because the managers are very understanding’. 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 internal quality assurance processes; these have been more formalised since our last visit. Surveys have recently been sent to residents and staff these are being returned and will provide information for the managers to analyse and use to plan future improvements. A number of appreciation cards were seen from grateful relatives of people who have used this service. Policies and procedures are in place and have recently been reviewed. Action has been progressed to implement requirements identified in our previous inspection report. Safety notices were displayed throughout the home including action to be taken in case of fire and how to Control of Substances hazardous to health. Written information provided to the inspector by the provider before the inspection indicates that all equipment is regularly maintained and tested. Records seen on the day of our visit confirmed this. Abbotsfield Hall Nursing Home DS0000003572.V331314.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X X X 3 Abbotsfield Hall Nursing Home DS0000003572.V331314.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP26 Regulation 13(3) Requirement To minimise the risk of cross contamination/infection - pots of cream must be used for the individual they are prescribed for only and these and soap bars must not be left in communal bathrooms. Extended for the third time from 01/09/05 and 01/03/06 AND 01/08/06 Timescale for action 01/08/07 2. OP26 18(1)(c) Because this standard has persistently not been met. The registered provider must ensure that the care staff have the training appropriate to the work they perform this must include training /updates about how to prevent and control infection. Medication administration records and labels on medication containers must not be changed unless dated and signed by the prescribing General Practitioner or at least 2 registered nurses. Failure to do this poses a risk to residents because there is no DS0000003572.V331314.R01.S.doc 01/12/07 3. OP9 13(2) 01/07/07 Abbotsfield Hall Nursing Home Version 5.2 Page 26 legal order for this change in medication frequency or dose. To prevent the risk of people not receiving medicines as prescribed you must ensure that all hand written entries are accurate and that all administrations of medicines are recorded, including the dose actually administered. 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 expectations of those people living in the home. Service users should have their social, cultural and recreational interests recorded including a plan on how to meet them. To ensure people are aware they have a choice of menu at each meal, the registered person should ensure the menu offers a choice and this is supplied in writing or other formats to suit the capacities of the service users which is given, read or explained to them. 2. OP15 Abbotsfield Hall Nursing Home DS0000003572.V331314.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Devon Area Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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