Inspection on 08/06/06 for Abbotsfield Hall Nursing Home

This inspection was carried out on 8th June 2006.

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

The inspector 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 18/04/08

Abbotsfield Hall Nursing Home 06/06/07

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 8th June 2006 10:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Abbotsfield Hall Nursing Home DS0000003572.V292744.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.V292744.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.V292744.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 21/02/06 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 with 16 single and 6 double rooms. The home is arranged on 2 floors with a passenger lift and stair lift available. A few rooms 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. Abbotsfield Hall Nursing Home DS0000003572.V292744.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The fieldwork visit of this inspection took place over 3hours and 40 minutes and was unannounced. A partial tour of the home took place when some bedrooms and all communal living rooms were viewed. Personal records of care of 3 residents and personnel records of 3 members of staff were inspected. The inspector spoke with 10 residents, 2 staff members the duty manager and administrator. Written feedback was received from 5 residents and 3 care workers and 1 visiting General practitioner. The homes senior staff had also submitted answers to a pre-inspection questionnaire supplied by the Commission. What the service does well: The admission process is safe; pre-admission information is supplied from care management or hospital settings about prospective residents. In addition to this information the senior nursing staff employed by the home visit prospective residents in their current setting to perform a full assessment of their needs this information is used to determine if/how the needs of the individual will be met at the home. Resident’s needs are set out in an individual plan of care; the care plans provide sufficient information for care staff to be able to meet the individuals’ health and psychological needs. The registered person promotes and maintains residents’ health and ensures access to health care services to meet their assessed needs. Residents are treated with respect and their right to privacy is upheld; the inspector observed that when personal care was being provided this was done behind closed doors, the staff spoke to residents in a polite manner and were witnessed to knock on the doors to private accommodation before entering. Some effort is made by the home to provide an activities programme and social interaction/stimulation for residents. Residents are able to maintain contact with family and friends and exercise choice and control over their lives. The lounges and dining room are all on the ground floor and are large, light and airy the temperature on the day of the visit was in the mid 20’s Centigrade however the windows provided ample cool ventilation and fans were seen in use in individuals rooms where natural ventilation was not as effective. There are usually sufficient numbers of staff with appropriate skills and knowledge to meet the needs of residents in this home; the home benefits from a stable staff team with many of the staff having been employed for a number of years. Many positive comments about the staff were received during Abbotsfield Hall Nursing Home DS0000003572.V292744.R01.S.doc Version 5.2 Page 6 the inspection visit and via surveys from residents and or their relatives/visitors, including: - ‘the carers and owners are very good here’ ‘carers and cleaners all very cheerful as a rule, a good atmosphere’, ‘the staff are always available’, ‘The staff are good and happy’, ‘the staff are very, very kind to me, they get top marks’. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. Abbotsfield Hall Nursing Home DS0000003572.V292744.R01.S.doc Version 5.2 Page 7 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Abbotsfield Hall Nursing Home DS0000003572.V292744.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.V292744.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The admission process is safe. This home does not provide intermediate care. EVIDENCE: The inspector randomly examined personal documentation held on behalf of 3 residents; all included pre-admission information supplied from care management or hospital settings about the residents assessed needs. In addition to this information the documents showed evidence that senior nursing staff employed by the home visit prospective residents in their current setting to perform a full assessment of their needs this information is used to assess if/how the needs of the individual will be mat at the home. The inspector spoke to a number of residents about how they had made the decision to be admitted to the home, one resident said they had heard about the homes good reputation from people who had visited the home. Another resident said they and their relative had been given the opportunity to visit before making a decision about their admission. Abbotsfield Hall Nursing Home DS0000003572.V292744.R01.S.doc Version 5.2 Page 10 Abbotsfield Hall Nursing Home DS0000003572.V292744.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s needs are set out in an individual plan of care. The registered person promotes and maintains residents’ health and ensures access to health care services to meet assessed needs. The homes medication system does not fully protect the medical welfare of residents. Residents are treated with respect and their right to privacy is upheld. EVIDENCE: The personal records examined which are held on behalf of residents. Contained assessments in relation to all activities of daily living and base line assessment of the peoples skin condition, moving and handling, nutrition and vital signs and weight these assessments had been repeated at, at least monthly intervals and provided information on which the care plans were based. There was evidence that the care planning process had been reviewed with the resident and their representatives where possible. The care plans Abbotsfield Hall Nursing Home DS0000003572.V292744.R01.S.doc Version 5.2 Page 12 provided sufficient information for care staff to be able to meet the individuals’ health, social and psychological needs. The inspector found one of the assessments had not been dated or signed by the assessing nurse. The documents held on behalf of the residents showed that the staff refer residents to the general practitioner appropriately. The Commission received written feedback from 1 visiting General Practitioner who rated the homes management of health and personal care for the residents as good. Letters regarding hospital appointments were seen providing evidence that residents are enabled to access specialist services according to need. 5 residents provided written feedback, 3 confirmed they always receive the medical support they need the other 2 indicated they usually received the medical support they need. An inspector examined the system for storing. Administering and recording of medication held in the home. The records of medication entering and leaving the home were of a good standard. The storage of medication was found to be safe. A dated national formulary (2002) and Mimms (2004) was available for staff to refer to if they needed. The inspector found that medication administration records and labels on medication containers had been changed with no date or signature, this poses a risk to residents because there is no legal order for this change in medication frequency or dose. When a change occurs the prescribing doctor should document the change and the dispensing pharmacy must ensure the label indicates the actual dose to be administered and when. Residents told the inspector that the staff respect their privacy and dignity, the inspector observed that when personal care was being provided this was done behind closed doors, the staff spoke to residents in a polite manner and were witnessed to knock on the doors to private accommodation before entering. Abbotsfield Hall Nursing Home DS0000003572.V292744.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 at least once during a 12 month period. 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. Some effort is made by the home to provide an activities programme and social interaction/stimulation for residents. Residents are able to maintain contact with family and friends and exercise choice and control over their lives. Residents receive a wholesome appealing diet but sometimes there is limited choice. EVIDENCE: The inspector found that some key information that would assist staff to offer appropriate social support to residents was not always transferred to the care plan, examples of this were information about past occupations and religion. Five residents provided written feedback about activities; when asked ‘Are there activities arranged by the home that you can take part in?’ one indicated always, two ‘usually’ and one indicated sometimes, written comments received were - ‘There are weakly music sessions –no exercise routines though. Mind I do a fair amount of sleeping in the afternoon’ ‘dependent on my health at the time’. Residents spoken to during the visit told the inspector that ‘sometimes there is a person invited in to the home to provide musical entertainment’. ‘I Abbotsfield Hall Nursing Home DS0000003572.V292744.R01.S.doc Version 5.2 Page 14 make occasional visits to the lounge I like having my own television with remote controls. Residents said they were able to make choices about how and where they spent their time, one confirmed they stayed in their room but that was their choice. On the day of the visit the inspector observed a visiting hairdresser providing stimulation for residents whilst doing their hair in one of the lounges, one of the residents had been the hairdressers post man before he had retired another resident had known the hairdresser for over a decade and had been attended by her at a previous care home, another had known the hairdresser since she was just a young girl. Most residents said the food provided in the home is of a good standard one commented ‘The food is good, I get what is delivered, not offered choice, accept what I get’. Written feedback from 5 residents was received 3 indicated they ‘usually’ like the food and the other 2 indicated they ‘always’ like the meals at the home. Lunch was served at the time of the inspection the main meal was chicken pie with 2 vegetables and potatoes followed by rice pudding. Residents were seen eating in the light and airy dining room, in their own rooms and those requiring assistance were given this whilst sitting in the lounge. During a tour of the premises the kitchen was found to be clean. Visitors were observed coming in and out of the home throughout the time of the visit the inspector witnessed a high level of interaction between the visitors, residents and staff. Residents told the inspector they were pleased with the visiting arrangements in the home and could see people privately in their own rooms or socially in the lounges or dining room. Abbotsfield Hall Nursing Home DS0000003572.V292744.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Most Residents and their relatives/friends know how to make a complaint. People are safe living in this home. EVIDENCE: Residents spoken with at the time of the inspection told the inspector they knew who to speak to if they were dissatisfied with the care or services provided. Complaints procedures were found displayed in the statement of purpose as well as in the Service Users Guide. Five residents provided written feedback; 2 indicated they ‘always’ know who to speak to if they are not happy, one ‘usually and one ‘sometimes’. When asked Do you know how to make a complaint three indicated ‘always’ one ‘sometimes’ and one ‘never’ a comment received was ‘I get muddled with the staff names and what they all wear so I don’t know who to approach’. The inspector read the homes policy and procedure relating to responding to allegations or incidence of abuse or neglect and found it to be written in plain English and informative. The policy was dated as reviewed 11/05/06. Abbotsfield Hall Nursing Home DS0000003572.V292744.R01.S.doc Version 5.2 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): 19,21,24,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some improvements have been made to the environment; despite this some areas remain in need of upgrading and redecoration. The home is clean and hygienic. EVIDENCE: The inspector performed a tour of the home and found that some improvements had been made to the environment since the last visit to the home. The inspector found that a number of doors had been fitted with ‘safe’ hold open devices but one door which has been wedged open on previous occasions situated on the 1st floor was indeed wedged open again this time with a portable room divider screen, the resident confirmed they liked their door open, this poses a risk of spread should a fire occur and a requirement has been made again that where residents want the doors to their bedroom open this must be done by a ‘safe’ hold open device following advice from the Abbotsfield Hall Nursing Home DS0000003572.V292744.R01.S.doc Version 5.2 Page 17 Devon Fire and Rescue department failure to do this may lead to enforcement action. In order to promote the privacy, dignity and security of residents a number of doors to individuals bedrooms have been fitted with locks. 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. The lounges and dining room are all on the ground floor and are large, light and airy the temperature on the day of the visit was in the mid 20’s Centigrade however the windows provided ample cool ventilation and fans were seen in use in individuals rooms where natural ventilation was not as effective. One comment received about the communal areas was ‘ I find the big sitting room difficult, its tall ceiling makes my hearing one speak awkward, I feel a bit lost in such a big room after my little home. If they could provide a small cosy room I imagine there’d be a queue to get in’. Residents were seen enjoying the fine weather in shaded areas of the large attractive garden. 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. Residents do not currently have an option to shower instead of bathe. Resident’s rooms contained personal items of furniture, ornaments and pictures. A tub of skin cream was found in a communal bathroom the tub did not contain the identity of the resident it was to be used for this is poor infection control practise. One shared bedroom with only one basin had 2 soap bars on the basin surround neither were in named receptacles this poses a risk that soaps may be ‘shared’ increasing the risk of cross contamination/infection. The environment was clean and odour free. Abbotsfield Hall Nursing Home DS0000003572.V292744.R01.S.doc Version 5.2 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are usually sufficient numbers of staff with appropriate skills and knowledge to meet the needs of residents in this home. The homes recruitment practise does not fully protect residents from being placed at risk of harm or abuse. EVIDENCE: Two care staff were spoken to at the time of the inspection and 4 staff completed and returned a survey to the Commission. The home benefits from a stable staff team with many of the staff having been employed for a number of years. Comments received included – ‘they try to accommodate everybody’ ‘the care home is a happy place to work, the meals are good, everything is cooked on the premises’ the home does really well at care for residents, staff and visitors and there is generally good clean upkeep to the building. All the staff whom returned surveys confirmed that in addition to receiving 1 to 1 supervision there are small group meetings held on a regular basis more often than 3 monthly. The inspector examined the personnel files of 3 staff members these contained documented evidence of the (topss) induction training they had received, which included moving and handling, Protection of vulnerable adults, fire safety and infection control. The personnel records provided evidence that on some occasions the last employer had not been approached to provide a reference or contained only one written reference. Abbotsfield Hall Nursing Home DS0000003572.V292744.R01.S.doc Version 5.2 Page 19 13 care staff have achieved a National Vocational Qualifications at level 2 or above and another member of staff is working towards it. In - house training has included moving and handling and fire safety and distance learning courses have been taken in infection control and health and safety. The home has an infection control link worker and continence management key worker who meet regularly and update their skills together with staff from the primary care trust. 8 staff have current first Aid certificates but are due for refreshers shortly. Many positive comments about the staff were received during the inspection visit and via surveys from residents and or their relatives/visitors, including: ‘the carers and owners are very good here’ ‘carers and cleaners all very cheerful as a rule, a good atmosphere’, ‘the staff are always available’, ‘The staff are good and happy’, ‘the staff are very, very kind to me, they get top marks’. Of the 5 residents who provided written feedback 3 indicate there are ‘always’ staff available when they need them and the other 2 indicated that the staff are ‘usually’ available when they need them. Abbotsfield Hall Nursing Home DS0000003572.V292744.R01.S.doc Version 5.2 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): 31,33,35,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Persons who are fit to be in charge and of good character manage the home. Personal money held in the home on behalf of residents is secure. The home lacks effective quality assurance and quality monitoring processes. The registered providers have failed to show a responsible attitude toward promoting and protecting the health, safety and welfare of residents and staff through consistently using unsafe items to hold open fire doors. EVIDENCE: This 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. The inspector witnessed a good level of communication between the manager on duty and the staff residents, visitors/relatives and visiting professionals. Abbotsfield Hall Nursing Home DS0000003572.V292744.R01.S.doc Version 5.2 Page 21 There is no documentary evidence of quality assurance or quality monitoring systems. The systems for measuring customer satisfaction are informal, the manager and provider told the inspector that they ask the residents verbally on a day to day basis if things are alright for them in the home. Action has not been progressed within agreed timescales to implement requirements identified in previous inspection reports. The inspector examined the storage and records of money held on behalf of residents in the home; a random number of these (2) had their records checked against actual balances, and were found to be accurate. The records contained only one signature and did not show evidence of regular auditing by the registered provider. The money is stored securely in the home. At previous inspections the inspector found that 1 bedroom situated on the 1st floor had its door held open with a wooden wedge, again during this inspection the resident told the inspector they liked to have the door open and this was usually done with a wooden wedge, but ‘the staff couldn’t find the wedge today’ and during this inspection the same door was wedged open with a piece of portable furniture (privacy screen). 2 requirements have been made on previous occasions to have ‘safe’ hold open devices fitted to doors where residents want them open. Despite this the same door has been consistently wedged open failure to do so on this occasion will lead to enforcement action being taken to ensure resident safety. Abbotsfield Hall Nursing Home DS0000003572.V292744.R01.S.doc Version 5.2 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 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 2 17 X 18 3 2 X 2 X X 2 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 1 X 3 X X 1 Abbotsfield Hall Nursing Home DS0000003572.V292744.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? 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 OP9 Regulation 13(2) Requirement 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 legal order for this change in medication frequency or dose. The registered persons should ask the dispensing pharmacy to update the label as this legal order indicates the actual dose to be administered and when. Timescale for action 01/07/06 2 OP19 23 3 OP24 12(4a) To ensure timescales that are set 01/08/06 for compliance with the physical environment of the home are recognised and met. A plan and programme for achieving compliance must be produced and followed with records kept. This relates to ‘safe’ hold open devices and locks to personal accommodation. To ensure residents have the 01/10/06 right to maintain their privacy, dignity and security. Residents bedrooms must have locks fitted DS0000003572.V292744.R01.S.doc Version 5.2 Page 24 Abbotsfield Hall Nursing Home that are suited to their capabilities and accessible to staff in emergencies. Extended from 01/04/06 4 OP26 13(3) 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 second time from 01/09/05 and 01/03/06 The registered person must not employ a person to work at the care home unless he has obtained in respect of that person all of the information and documents specified in paragraphs 1 to 7 of Schedule 2 of the care home regulations. The registered person must establish and maintain a system for reviewing and improving the quality of care including nursing provided at the home. The registered person must supply to the Commission a report in respect of the review and make a copy of the report available to service users. The system of review must provide for consultation with service users and their representatives. The registered person must supply ‘safe’ hold open devices (as approved by Devon fire and rescue department) to doors to residents’ private accommodation where they wish to have their doors open. Extended for the 3rd and final time from 01/10/05 and 01/04/06 01/08/06 5 OP29 19 01/07/06 6 OP33 24 01/09/06 7 OP38 13(4) 23(4) 01/09/06 Abbotsfield Hall Nursing Home DS0000003572.V292744.R01.S.doc Version 5.2 Page 25 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. The registered person(s) should ensure the complaints procedure provides for all residents to be aware of how and to whom complaints may be made. Consideration should be given to providing a shower room suitable for use by both independent and physically dependent residents. 2 OP15 3 4 OP16 OP21 Abbotsfield Hall Nursing Home DS0000003572.V292744.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Abbotsfield Hall Nursing Home DS0000003572.V292744.R01.S.doc Version 5.2 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. 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