Inspection on 14/10/08 for Abbotsford

This inspection was carried out on 14th October 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

Abbotsford 09/07/07

Abbotsford 19/07/06

Abbotsford 05/04/05

Abbotsford 16/08/04

Abbotsford 20/04/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 19/12/2008.

CARE HOMES FOR OLDER PEOPLE Abbotsford 443 Wellingborough Road Abington Northampton Northants NN1 4EZ Lead Inspector Sally Snelson Unannounced Inspection 14th October 2008 08:05 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 Abbotsford DS0000040840.V371220.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. Abbotsford DS0000040840.V371220.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbotsford Address 443 Wellingborough Road Abington Northampton Northants NN1 4EZ 01604 636729 01604 636729 abbotsfordcare@majproperties.co.uk 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) Msaada Care Limited Manager post vacant Care Home 18 Category(ies) of Dementia - over 65 years of age (18), Old age, registration, with number not falling within any other category (18) of places Abbotsford DS0000040840.V371220.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered persons may provide the following category of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission are within the following categories: Dementia over 65 years of age - Code DE(E). Old age, not falling within any other category - code OP. The maximum number of service users who can be accommodated is 18. 9th July 2007 2. Date of last inspection Brief Description of the Service: Abbotsford is a care home for 16 people over the age of 65 years who have dementia related conditions. Accommodation is set over three floors, rooms on the second floor and annex the are single with en-suite facilities, rooms on the first floor are all shared and do not have en-suites. There are two lounges and a separate dining room. The home is located on a main road and is opposite a park. The town centre is two miles away and is on the local bus routes. The current fees range from £350 to £450 per week and additional charges are made for hairdressing services and chiropody. Abbotsford DS0000040840.V371220.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. This inspection was carried out in accordance with the Commission for Social Care Inspection’s (CSCI) policy and methodologies, which requires review of the key standards for the provision of a care home for older people that takes account of residents’ views and information received about the service since the last inspection. Information from the home, through written evidence in the form of an Annual Quality Assurance Assessment (AQAA) (this was requested earlier in the year) has also been used to assess the outcomes within each standard. Evidence used and judgements made within the main body of the report include information from this visit. Sally Snelson and Louise Trainor undertook this inspection of Abbotsford. It was a key inspection, was unannounced, and took place from 08.05am on 14th October 2008. Michelle Poole, the manager, was present from 08.30 hrs. Feedback was given throughout the inspection, and at the end. During the inspection the care of three people who use the service (residents) was case tracked in detail. This involved reading their records and comparing what was documented to what was provided. In addition to sampling files, people who lived at the home, visitors, and staff were spoken to, and their opinions sought. Any comments received from staff or residents about their views of the home, plus all the information gathered on the day was used to form a judgement about the service. The inspector would like to thank all those involved in the inspection for their input and support. What the service does well: The people using the service that we spoke to were clearly happy with the care they received. One gentleman said, “I love it here, I have been here a long time, I came from hospital - they look after me really well. Abbotsford DS0000040840.V371220.R01.S.doc Version 5.2 Page 6 People using the service had been assessed prior to their admission. The manager understood the importance of ensuring that the home had the resources to meet the needs of prospective residents prior to admission. Care plans were written in detail and described the necessary treatment. The plans included a detailed social assessment and life history that could be built upon as the staff got to know the resident. People using the service were appropriately referred to other health professionals such as a physiotherapist and a continence advisor. The home was clean and tidy and additional touches such as fresh flowers made it homely. In the short time the new manager had been in post she had worked hard to make a number of necessary changes. She was committed to providing a good service and showed that she had plans for the home and was working logically to fulfil these plans. What has improved since the last inspection? What they could do better: At the conclusion of the inspection we fed our findings back to the manager and gave her an indication of the requirements and recommendations we were going to include. These included: • The need to store controlled drugs correctly and ensure staff accurately record exactly what dose of medication has been given. • The need to ensure the complaints procedure and policy are appropriate to the needs of the service users. • The need to ensure all staff must have an understanding of the homes safeguarding policy and that the policy must link to the Local Authority safeguarding policy • The need to ensure that all staff receive the training they need to provide the appropriate care. • Staff must not start work until all the correct references and checks are completed. • The statement of purpose and service users guide should be available to all people that use the service and their representatives. Abbotsford DS0000040840.V371220.R01.S.doc Version 5.2 Page 7 • The home should be flexible to the needs of the residents so that people using the service are treated as individuals. • There should be a wider range of activities that suit the individual needs of all the individuals living at Abbotsford. 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. Abbotsford DS0000040840.V371220.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 Abbotsford DS0000040840.V371220.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): 1,2,3,4,6, People who use this service experience adequate quality outcomes in this area. The manager understood the importance of ensuring that the home had the resources to meet the needs of prospective residents. However sufficient information about the home, is the form of a Statement of Purpose and Service Users Guide, was not available. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The manager told us that she was aware that the Statement of Purpose needed to be updated to reflect the staff changes and a new Service Users Guide needed to be produced. The manager had sourced copies of other services brochures and guides to help her with this task. Abbotsford DS0000040840.V371220.R01.S.doc Version 5.2 Page 10 In the file of a resident who had only been at the home for a short while we saw an agreement signed by management, but it had not been signed by the resident or a representative on their behalf. We did not see these documents in other files. We saw clear evidence that people using the service had been assessed prior to their admission. The assessment included their physical and social needs. The manager told us that following one assessment it had been apparent that the home was not suitable for a particular person, and she had told the placing social worker she could not accept the admission even though it was a home the family would have liked their relative to move to. This decision is to be commended and ensures that people living at Abbotsford can be cared for in a suitable environment and by an appropriately trained staff team. Abbotsford did not offer intermediate care. Abbotsford DS0000040840.V371220.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 People who use this service experience adequate quality outcomes in this area. The needs of people using the service could be fully met by staff following the detailed care plans describing the necessary treatment. However controlled drugs were not being stored correctly. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: During the case tracking of three residents we saw very detailed needs assessment in place that clearly informed staff how to provide the correct care. It was apparent that the initial assessment completed upon admission was added to as staff received more information about the person using the Abbotsford DS0000040840.V371220.R01.S.doc Version 5.2 Page 12 service. The care plans had been well written under all the headings of daily living and were kept under review. To be improved the associated risk assessments and other assessments should be routinely stored with the particular care plan. For example under the heading of mobility it should be clear as to how a person in moved, and the risks associated with moving and handling. All the information was in the file but it was not always with a particular care plan. The manager informed us that she was planning to work with the staff so that everyone could be involved in writing and reviewing care plans. Currently all of the residents were registered with one local GP surgery and the manager told us the home had a good relationship with the community nurses and could request advice. We were aware that people using the service were appropriately referred to other health professionals such as a physiotherapist and a continence advisor. We were pleased to note that where advice had been given the staff had implemented this, and the care plan altered to reflect the changes. On the day of the inspection a community audiologist was visiting the home. We looked at the Medication Administration Records (MAR) for seven people. Charts had been completed when medications had been administered and codes to indicate any omissions had been used correctly. Unfortunately because staff failed to indicate what dose they had given when a variable dose was prescribed we were unable to reconcile all the medications that were not in blister packs. Controlled drugs were stored in a coded safe in a locked cupboard. In 2007 the law changed. All care homes, whether providing nursing or personal care, must now keep controlled drugs (CD) in a controlled drugs cupboard. In brief, the requirements for CD storage are: •metal cupboard of specified gauge •specified double locking mechanism •fixed to a solid wall or a wall that has a steel plate mounted behind it •fixed with either Rawl or Rag bolts. We also noted that CDs removed by the pharmacist following a resident death had not been correctly signed out of the home. We saw people being treated kindly and with respect and we noted that care plans included information about the person’s preference for the gender of the staff member providing their personal care. However we were concerned that at the beginning of the inspection (approximately 8am) most of the residents were sitting in the lounge. At about 8.30am a staff member came to them and said, “time for breakfast”, and everyone got up, or were helped to the dining room at the same time. We would have liked to have seen people being given the opportunity to have their breakfast when they got up. One lady said we Abbotsford DS0000040840.V371220.R01.S.doc Version 5.2 Page 13 have to get up for breakfast, we cant have it in bed, another said “ I am always hungry in the morning”. A number of the residents told us that they had not been offered an early morning cup of tea. The manager believed that the night staff routinely offered an early morning drink and was intent on ensuring it would happen in the future. People were dressed in their own clothes and it was apparent that those who could dress themselves choose what they wanted to wear for themselves. However, while we were sitting with residents in the lounge, one person asked us to ring the call bell for him and call a member of staff as he was uncomfortable in the jumper that he had been put in as it had a ripped sleeve. Abbotsford DS0000040840.V371220.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 People who use this service experience adequate quality outcomes in this area. At the time of the inspection there was not a wide range of activities offered, but the manager had plans to make the necessary changes to offer residents more stimulation throughout the day. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: As already mentioned we believed that some of the routines of daily living were not very flexible and may not suit all the residents’ expectations and preferences, for example mealtimes and in particular the timing of breakfast. When discussing the activities in the home the manager said to us “I know it is not fantastic, but it is going to be, I have a plan”. She had already delegated a member of staff for each shift to be responsible for activities. This was in an attempt to encourage all the staff to be responsible for activities and not leave Abbotsford DS0000040840.V371220.R01.S.doc Version 5.2 Page 15 it to an activity co-ordinator. The duty rota indicated who this person was to be. The manager had bought some additional recreational equipment, and resident’s friends and families had been encouraged to help and make suggestions for activities. We discussed with the manager the need to ensure that some of the activities were suitable for those people with dementia and would appear meaningful to them. The activity plan displayed was very out of date, but we were aware that people had recently enjoyed using a karaoke machine, playing a memory game and hand massages, although none of these activities were on the advertised plan. The AQAA informed us, we have two outside entertainers that attend monthly we have regular weekly visits from hairdresser and the pat dog. Three monthly visits from the chiropodist and a family member who intermittently holds hymn sessions. Care plans included a detailed social assessment and life history that could be built upon to ensure that activities were appropriate for the people using the service. We witnessed people being offered a choice at breakfast time and one gentleman told us that he enjoyed four of his favourite breakfast cereal most mornings. Lunch on the day of the inspection was fish pie or a ham salad. We were concerned that the habit of offering only one hot choice for the main meal needed to be reviewed for the winter. Abbotsford DS0000040840.V371220.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 People who use this service experience adequate quality outcomes in this area. The complaints procedure was displayed in the home, but it was not completely up-to-date and could encourage people wanting to make a complaint to contact the wrong agencies. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: There was a copy of the homes complaints policy displayed in the entrance of the home. Although the policy had been altered to reflect the new manager, some other changes needed to be made. For example it referred to our Northampton office, which had been closed and replaced by a regional office in Cambridgeshire. The document gave a number of people who could be contacted, including the acting manager, us, the director of Msaada, an advocate and parents in partnership. We discovered by contacting Parents in partnership that it was an advocacy organisation for parents of young people with a learning disability, and not appropriate for Abbotsford residents. We were told that management were in the process of updating the complaints policy. Abbotsford DS0000040840.V371220.R01.S.doc Version 5.2 Page 17 The manager was aware of the need to document any verbal or written complaints, the investigation process, and then record the outcome within residents personal file and in the homes central record of complaints. Since managing the home the manager had not had any complaints made to her about the service. We had had one complaint made to us about the running of the home. This had not been substantiated. We put a safeguarding scenario to the manager and she was a bit hesitant as to how she would react, and we believed she might investigate more than she should. However she was aware of the agencies that should be contacted and admitted to be confused by our questioning. The manager had identified the staff that needed to have Safeguarding training updated, and we felt confident she would revisit the procedure herself. Abbotsford DS0000040840.V371220.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): 19,24,26 People who use this service experience adequate quality outcomes in this area. The home was clean tidy and homely but would benefit from some redecorating in some communal areas. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The home was clean and tidy and additional touches such as fresh flowers made it homely. Residents could move freely between the two communal lounges and the dining room. There was a need for the front of the house to be tidied regularly as the home was opposite a park and rubbish collected regularly. The home felt warm despite the inspection starting early on an Abbotsford DS0000040840.V371220.R01.S.doc Version 5.2 Page 19 autumnal day. We did however note that there was a portable heater in each of the lounges; one was plugged in and was switched on, and the other was unplugged. We did not see any risk assessments to support the use of additional heaters and the trailing leads. A curtain was off the track in the lounge. There were large signs and pictures on the doors to help those people with dementia find their way around. We were disappointed to see signage on the lounge window that stated, “ it is against the law to smoke on these premises”, this was not at all homely. The home had a number of shared bedrooms. We heard varying opinions of these. One resident told us, “I have got a double room, but I am on my own, I am not looking forward to sharing”, and we were also told of a resident who did not want to be alone and insisted on sharing. Two of the shared rooms were only being offered as single rooms. It was apparent that people could individualise their bedrooms and were encouraged to bring in small pieces of furniture, photographs, pictures and ornaments from their own home to do this. The floor covering in the dining room was not appropriate for a dining room and some of the communal areas were carpeted with carpets that had big patterns and were not at all suitable for people with dementia. Abbotsford DS0000040840.V371220.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 People who use this service experience adequate quality outcomes in this area. Recruitment procedures were not completely robust. The manager had identified the gaps in staff training and was ensuring it was delivered as soon as possible. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The duty rotas confirmed, and the manager told us, that in addition to herself and ancillary staff, there were three staff on duty at all times during the day and two at night. There were currently vacancies at the home and the manager was hoping to appoint two seniors to support her and take responsibility in her absence. The home did not use agency staff and were able to cover the vacancies by staff working extra shifts, which they were happy to do. In the short time the manager had been in post she had been through all the staff files and identified training gaps. She had sourced awareness videos to ‘plug’ the gaps immediately, and was sourcing a variety of training through the Abbotsford DS0000040840.V371220.R01.S.doc Version 5.2 Page 21 Local Authority and other training venues. Most of the ‘missing’ training had been booked and was to take place in the foreseeable future. A new member of staff was able to talk to us about her induction and the induction pack she was working through. We looked at the recruitment files for three staff members, including one who had recently been employed. It was apparent that the company management interviewed new recruits and the manager was not always involved in the process. The manager told us she expected this to change and that ideally she would like to interview new recruits at the home so they had a chance to see where they were to work. Two of the files we looked at had the correct references and checks but the third had only one reference. The Human Resource manager told us the second was on its way and as the first was so good they had made the decision to start the carer. This is not acceptable. We also experienced some difficulty working out exactly when a member of staff had started work as the company dated the terms and conditions documentation on the day the position was offered. The human resource manager agreed that in future this document would be amended to include the date employment commenced. According to the AQAA at the time of the inspection only four of the 13 staff had NVQ level 2 or above and another one was working towards it. It was expected that at least 50 of staff would have NVQ level 2 by 2005 so this needs to be given priority in the coming year. Abbotsford DS0000040840.V371220.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): 31,33,35,36,38 People who use this service experience adequate quality outcomes in this area. In the short time the new manager had been in post she had worked hard to make a number of necessary changes. She was committed to providing a good service. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The manager had been in post for a few months and was working towards her NVQ level 4. She appeared committed to her role and the challenge of Abbotsford DS0000040840.V371220.R01.S.doc Version 5.2 Page 23 becoming the registered manager; she had not yet applied to us to become registered. The residents spoke of her warmly, and she had a good rapport with them and with the staff. In the short time the manager had been in post she had sent out quality assurance questionnaires to residents and their families and to other stakeholders such as the GP. She had already drawn a conclusion of the responses and had written a report and acted on the received information. The home held small amounts of petty cash on behalf of some of the residents we sampled three of these and noted that receipts were correctly kept and the money held reconciled to that on the balance sheet. Receipts were mainly for hairdressing, chiropody or toiletteries. Since the resignation of the previous manager the acting manager had been supervising the staff. The staff team had not been used to this and felt threatened by it and did not see it as a positive event. The manager was planning ways of making the sessions as pleasant and useful as possible. The manager was able to demonstrate that Health and safety systems were in place and kept up to date. Abbotsford DS0000040840.V371220.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 2 2 3 3 x N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X X X 3 X 3 STAFFING Standard No Score 27 2 28 1 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 2 X 3 Abbotsford DS0000040840.V371220.R01.S.doc Version 5.2 Page 25 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 2 Standard OP9 OP9 Regulation 13(2) 13(2) Requirement Controlled drugs must be correctly stored in the home. Care must be taken that when medications are administered the medication record is completed accurately to record exactly what has been given. The complaints procedure and policy must be appropriate to the needs of the service users. All staff must have an understanding of the homes safeguarding policy and the policy must link to the Local Authority safeguarding policy. Staff must receive the training, and the updates of the training, that they need to provide the appropriate care. In all circumstances staff must have all the required checks and references before being offered employment. Timescale for action 01/12/08 01/12/08 3 4 OP16 OP18 22(2) 18(1)(a) 01/12/08 01/12/08 5 OP28 18 (1) 01/01/09 6 OP29 19 14/10/08 Abbotsford DS0000040840.V371220.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 3 Refer to Standard OP1 OP2 OP10 Good Practice Recommendations The homes statement of purpose and service users guide should be available within the home for all people that use the service and their representatives. All residents should have a contract that has signed by them or a representative on their behalf. Consideration should be given to treating people as individuals for example offering them breakfast at a time that suits them and not a time that is more convenient for the staff. A wider range of activities that suit the individual needs of all the individuals living at Abbotsford must be considered. People using the service should be offered the choice between two hot meals for their main meal. Consideration must be given to the manager becoming the registered manager. 4 5 6 OP12 OP14 OP15 OP31 Abbotsford DS0000040840.V371220.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Abbotsford DS0000040840.V371220.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. 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