CARE HOMES FOR OLDER PEOPLE
Abbotsford Nursing Home 8/10 Carlton Road Whalley Range Manchester Lancashire M16 8BB Lead Inspector
Geraldine Blow Unannounced Inspection 2nd February 2006 08:15 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 Nursing Home DS0000062280.V279093.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Abbotsford Nursing Home DS0000062280.V279093.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Abbotsford Nursing Home Address 8/10 Carlton Road Whalley Range Manchester Lancashire M16 8BB 0161 226 8822 0161 226 4430 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) Abbotsford Care Home Limited Ms Sally Ann Hughes Care Home 44 Category(ies) of Learning disability (1), Old age, not falling registration, with number within any other category (40), Physical of places disability (3) Abbotsford Nursing Home DS0000062280.V279093.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. The maximum number of service users accommodated shall be 44. Nursing care is provided for a maximum of 34 older people aged over 60 years. Three service users are accommodated out of category by reason of age. When these service users leave, the service user category will revert to old age. One named individual is in receipt of personal care by reason of learning disability. When this service user leaves, the service user category will revert to old age. Minimum nursing staffing levels as specified in the Staffing Notice issued under Section 13 of The Care Standards Act 2000 on 4 July 2005 must be maintained. Staffing for the service users assessed, as requiring personal care only must comply with the minimum levels set out in the Residential Forum for Staffing in Care Homes for Older People. As detailed in the Statement of Purpose the home must continue to provide the appropriate level of services to meet the specific social, cultural and religious needs of the Chinese service users accommodated at the home. The service must employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 5th July 2005 4. 5. 6. 7. 8. Date of last inspection Brief Description of the Service: Abbotsford provides accommodation for a maximum of 44 residents. The home is registered to accommodate 34 older people assessed as requiring nursing care. The registered provider is Abbotsford Care Home Limited and the Responsible Individual is Mr Joseph Heiftz. The home is situated in a residential area in the South of the City of Manchester. Local facilities and bus routes are within easy walking distance. There are parking facilities to the front of the property. Abbotsford Nursing Home DS0000062280.V279093.R01.S.doc Version 5.1 Page 5 The building is a spacious detached Victorian house set in its own grounds. The home provides accommodation to a number of Chinese residents. Accommodation is provided on four floors. There are 29 single bedrooms containing a wash hand basin and 11 single bedrooms with en-suite facilities. There are 2 double rooms providing en-suite facilities. There are 3 lounge/dining rooms and a designated smoking area. Abbotsford Nursing Home DS0000062280.V279093.R01.S.doc Version 5.1 Page 6 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection, conducted by 2 inspectors and the Pharmacist inspector. The inspection took place on the 2nd February 2006. During the inspection, time was spent talking to the manager, several of the residents, a visiting hairdresser and some members of staff to find out their views of the home. Documents including staff and residents’ files, records and other relevant documentation were also examined. Since the last inspection, the home has had 2 allegations of abuse. One was being investigated as part of this unannounced inspection and one has been appropriately concluded. It is commendable that the majority all of the requirements made at the last inspection had been met. During the course of the inspection, some concerns were raised as to the name of the registered provider. A separate letter has been sent to the Responsible Individual for clarification. During this inspection only a selection of the key National Minimum Standards were assessed. Therefore in order to gain a full picture of how the home meets the needs of residents, this report should be read with the previous reports to gain a full picture of how the home is meeting the needs of the people living there. What the service does well:
Through discussions with the manager and staff it was obvious that the home was committed to improving the service delivered to residents. Staff greeted visitors at the door with a welcoming response and escorted the visitor through the home. The atmosphere of the home felt relaxed and peaceful. The residents appeared well dressed, happy and settled. Staff were seen to have good relationships with the residents and appeared kind and sensitive in their approach. It was evident from progress made with the individual profiles that the home was concentrating efforts on seeking the views of the residents in order to develop all aspects of care in the home. There had been considerable efforts made to develop access to activity and leisure activities in consultation with residents living in the home.
Abbotsford Nursing Home DS0000062280.V279093.R01.S.doc Version 5.1 Page 7 The manager was very visible and approachable. During the inspection the manager stopped and spoke with any resident that she passed. The residents and staff seemed to benefit from her strong leadership approach and her open door policy. All staff spoken to stated satisfaction with the management style and expressed a positive attitude at how the home had progressed and developed to provide improved care to residents in the home. One member of staff said that the manager demonstrated a commitment to residents and staff in the home. The home’s hairdresser said, “the manager here is wonderful, she is great with the residents and they all love her”. What has improved since the last inspection? What they could do better:
Although the care planning process had greatly improved a number of shortfalls were seen in one of the files examined. The home had not documented which pressure-relieving mattress the resident was on and the recording of the wound redressing was not consistently recorded in the same place. Also, the home must make sure that it accurately records, on a daily
Abbotsford Nursing Home DS0000062280.V279093.R01.S.doc Version 5.1 Page 8 basis, the nursing care delivered to each resident. Evidence must be provided that the plan of care is drawn up the involvement of the resident or their representative. On examining one care file it was noted that the home had appropriately referred a resident to the Tissue Viability (TV) nurse for advise. However the referral had not been followed up in a timely manner. The requirement made at the last inspection that an audit of all staff files must be conducted to make sure that staff are safe to work with residents had not been made and must be done as a matter of some urgency. During the inspection it was noted that the concrete flags to the side and rear of the property were covered in a green moss. This is a potential risk to residents and a risk assessment must be undertaken and the flags cleaned. Also the rubbish, such as the old bath and fridge freezer, stored in the garden must be removed. It appeared that staff were having informal supervision sessions. All staff must have formal supervision at least 6 times a year. In January 2006 the home had had an inspection by the Greater Manchester Fire and Rescue Service and some areas of non-compliance were identified. The home must ensure that it meets the required action identified in the report. A further inspection is scheduled for April 2006. 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. Abbotsford Nursing Home DS0000062280.V279093.R01.S.doc Version 5.1 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 Abbotsford Nursing Home DS0000062280.V279093.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): No judgement was made at this inspection EVIDENCE: As required at the last inspection each resident had been given a copy of the updated Service User’s Guide and a copy was given to the inspector during the course of the inspection. It was noted that some of the amendments had been hand written within the guide. It is recommended that the Guide be amended and re-printed. In addition it is recommended that the Service User’s Guide contain information regarding the relevant qualifications and experience of the manager and staff in accordance with Standard 1.2 of the National Minimum Standards. The remaining core standards were assessed during the previous inspection. Abbotsford Nursing Home DS0000062280.V279093.R01.S.doc Version 5.1 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 and 9 Overall the health and personal care needs of the residents appeared to be met at the home. The home’s medication procedures had sufficiently improved to provide a good administration system that served to protected residents. EVIDENCE: A random sample of care files were inspected and as part of a Protection of Vulnerable Adults investigation a specific plan of care was also inspected. As already stated in this report, the standard of care planning had greatly improved and it was obvious the home had worked hard to improve the overall standard. In the main, the plans of care were found to be detailed, informative and clearly set out the action that needed to be taken by care staff to ensure that all aspects of health, personal and social care needs of the residents were met. Appropriate risk assessments had been included and the plans of care had been reviewed on a monthly basis to reflect changing needs and current objectives for health and personal care. However, some shortfalls were
Abbotsford Nursing Home DS0000062280.V279093.R01.S.doc Version 5.1 Page 12 identified in 1 of the files inspected. The plan of care stated that the resident required a pressure relieving mattress and regular pressure relief but no evidence could be found that the mattress had been provided for the resident or that regular pressure relief had been given. An appropriate referral had been made to the Tissue Viability nurse, however, it was clearly documented that the pressure sore was deteriorating but a second referral was not made until 20 days later, in which time the sore deteriorated even further. The system for the recording of wound redressing and a progress report was not consistently followed. It is recommended that all staff follow the same procedure. In addition it is recommend that the manager gets resident/representative consent and takes photographs of pressure sores/wounds and records accurate measurements to track their progress. It had been documented that on the 30/11/05 the GP had requested that the observation of a resident be recorded. From the 30/11/05 to the 5/12/05 only one recording had been documented. Following an inspection by the Pharmacist inspector, there are several areas in which the policy and procedures must be developed and refined in order to maintain residents safety. These areas include how to handle medication that is prescribed ‘as directed’ or ‘as required’, leave medication; how to record changes of medication and medication on admission. The record keeping regarding the receipt, administration and disposal of medication was in the main accurate. The record keeping surrounding the receipt of liquid medication must be reviewed. There was a new system of recording residents current medication and the changes to that medication. The system was excellent in principle, but the records were inaccurate. If the sheets are to be used effectively they must be accurate and kept up to date as reliance on old and inaccurate information is dangerous. The home could not produce current information on each person’s medication on the day of inspection. All current and waste medication is securely stored. The storage areas are neat and well maintained. The temperature of the main storage room must be monitored, as the room was very warm. Medication must be stored within manufacturers guidelines. Stocks of medication are stored in the upstairs clinical room on open shelving. This medication must be securely stored. The records provide evidence that medication is being administered in accordance with the prescribed directions. There was some concern that nurses had altered dose frequency of medication without correct authorisation from the GP. All medication dose changes must be documented and nurses must work within NMC guidelines. The controlled drug stock and register were accurate.
Abbotsford Nursing Home DS0000062280.V279093.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 and 14 Daily routines in the home demonstrated that residents were encouraged to maintain control over their lives and social activities were sufficient to meet the expectations and preferences of residents in the home. EVIDENCE: Since the last inspection the home has established a leisure activity programme based on the needs and interests of residents in the home. The home maintained a record of all activities that had taken place, and provided information on which residents had participated and of those who had refused. This enabled the manager and staff to monitor activities and cross reference to reviews and service user consultations. Activities included entertainment from visiting artists, film afternoons, bingo; pet visits, and trips out to a Chinese restaurant to celebrate Chinese New Year, and a canal trip. There was evidence that activities were taking place approximately three times a week. Other ‘in house’ activities included hand and foot massage sessions. The care plans included a resident profile, which provided evidence that consultations had taken place with residents to establish their social interests, hobbies, leisure interests, family background and cultural and religious needs. The manager stated her intention to develop the profiles further adding additional information when possible. The manager was aware that the leisure
Abbotsford Nursing Home DS0000062280.V279093.R01.S.doc Version 5.1 Page 14 and activity programme must continue to be developed with residents on an ongoing basis. Residents and staff confirmed that activities had improved in the home. Routines in the home were flexible and designed to reflect individual needs and preferences. The Service User’s Guide provided information about maintaining contact with family and friends. It was evident through discussion with the manager and staff that families were actively encouraged to visit and become involved in life at the home. Abbotsford Nursing Home DS0000062280.V279093.R01.S.doc Version 5.1 Page 15 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Policies, procedures and training measures were in place to protect residents from neglect and abuse. Residents’ views were listened to and a complaints procedure was in place. EVIDENCE: The home used the Manchester Multi Agency Policy for The Protection of Vulnerable Adults from Abuse including the Department of Health Guidance ‘No Secrets’. Since the last inspection the home had developed the policy and procedures on adult protection. Information in the policy included details of the different types of abuse and provided staff with guidance on what action to take in the event of an allegation of abuse. The guidance had been altered to reflect the Manchester Multi Agency Policy for the Protection of Vulnerable Adults form Abuse that clearly states that all allegations of abuse must be referred to social services that take the lead in any investigations. The manager was aware that if the home develops any supplementary information on adult protection these must be in line with the Manchester Multi Agency Policy. The policy document includes a copy of a staff declaration confirming that they have read and understood the policy on adult protection. Abbotsford Nursing Home DS0000062280.V279093.R01.S.doc Version 5.1 Page 16 The manager stated that six members of staff had received ‘in house’ training in August 2005 to update them on adult protection issues. The manager had also attended a course on adult protection on Thursday 19 January delivered by Manchester Social Services. The manager stated her intention to cascade the information from this course to all staff in the home. In discussion with staff it was evident that they had a good understanding of issues surrounding abuse. Staff were aware of policies and procedures designed to protect residents from abuse and knew the procedures to follow in the event of any allegation of abuse. Since the last inspection two complaints had been received by the home and the Commission for Social Care Inspection. The complaint received on 09/08/05 was an allegation of abuse. The manager followed procedures and made a referral to social services that took the lead in the investigation. The latest complaint was an allegation of abuse and an investigation was ongoing at the time of this inspection. Residents spoken to seemed confident in approaching the manager or staff with any issues of concern. Abbotsford Nursing Home DS0000062280.V279093.R01.S.doc Version 5.1 Page 17 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 Improvements had been made to the home’s décor in order to provide clean, comfortable surroundings for residents. EVIDENCE: As already stated in this report, a number of improvements had been made to the décor and furnishings within the home. The manager stated that is was a continuing area of development. During the inspection it was noted that the paving to the side of the property was covered in a green moss. This is a potential trip hazard for residents therefore a risk assessment must be completed and the flags must be cleaned and the moss removed. Also, the items of rubbish stored in the back garden area must be removed. Abbotsford Nursing Home DS0000062280.V279093.R01.S.doc Version 5.1 Page 18 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29 and 30 Some shortfalls in the agency’s employment and recruitment procedures could potentially place service users at risk. Staff received training enabling them to meet service users care needs. EVIDENCE: The manager said that she did review the dependency levels of the residents to ensure that sufficient staff were provided to meet their assessed needs and staff were seen in what appeared to be sufficient numbers. However, the manager said that she could not provide evidence that the reviews had taken place. Therefore the requirement has been reiterated in this report. The file of a newly recruited member of staff was examined and contained all the documentation as required by Schedule 2 of The Care Homes Regulations 2001. Two written references were included on the file and a medical declaration stating fitness for work. Some shortfalls were noted in the documentation, this included a copy of the work permit instead of the original. There was evidence of a completed induction, which was in the format of a basic checklist. Consideration should be given to developing the induction process to demonstrate competency levels of the staff and to include some reference to induction course material. The manager must develop induction process in line with Skills for Care. Abbotsford Nursing Home DS0000062280.V279093.R01.S.doc Version 5.1 Page 19 A second staff file was examined. This did not contain a current Criminal Record Bureau check (CRB), which was relevant to her employment at Abbotsford. Also there were issues of concern on the file, which should have been discussed with the staff, and appropriate recording should have been made to document any investigation into the issue of concern. The manager stated that a number of staff who were already employed at the home prior to her taking the post of manager, had not got a current CRB disclosure on file. A requirement has been made to ensure that all files are audited and checked and that all staff must have a CRB disclosure to ensure the protection and well being of the service users in the home. The manager had applied to be the counter signatory for CRB checks. There had been improvement in staff training and development in the home. The manager stated that 85 of staff had NVQ Level2. The manager had developed a training and development record. This document provides details of training, outcome, certificates and identifies any future training needs. There is also a place to record mandatory training updates. There was evidence that the manager had accessed a wide range of training for staff in care related and health and safety topics. These included optical awareness, COSHH, fire training, continence training and manual handling. Staff who were spoken to during the inspection confirmed that training had been provided. Abbotsford Nursing Home DS0000062280.V279093.R01.S.doc Version 5.1 Page 20 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 36 and 38 Polices and procedures were in place to promote the health, safety and well being of residents in the home. EVIDENCE: The residents in the home benefit from a committed manager and the development of a staff team with a positive attitude. The manager operates an open management style and encourages residents and staff to make use of the ‘open door’ policy. At the heart of this style of management is a person centred approach where the focus is on how the individual resident wants their care needs to be met. All residents spoken to during the course of this inspection expressed satisfaction on the way the home was run and the quality of the services delivered by the staff in the home.
Abbotsford Nursing Home DS0000062280.V279093.R01.S.doc Version 5.1 Page 21 There was evidence that staff were supported and supervised informally, however, a formal structured supervision programme had not yet been implemented. The manager is aware that a formal supervision programme must be developed for all staff. The home received a visit from the Greater Manchester Fire Authority 19/01/06. The visit listed four areas of non-compliance as follows: 1) Inadequate means of escape 2) Inadequate training 3) Inadequate signage 4) Inadequate records. A list of remedial action has been provided by the Fire Department. The manager must ensure that action is taken to address all the requirements made by the Greater Manchester Fire Authority. The manager must also develop a suitable fire risk assessment. The manager confirmed that action had been taken to address some of the issues and arrangements had been made to improve fire exit arrangements and signage had been ordered. There was evidence that mandatory training had been held for all staff on Monday 23rd January 2006. However, there was no evidence of staff signatures to indicate participation. The manager said that they were waiting for certificates of attendance for all staff who participated. There was documentation to evidence that the manager monitored all health and safety issues in the home. During a recent inspection of the passenger lift, on 1/2/06, the engineer had identified a problem. The manager had completed appropriate risk assessments detailing the hazard and control measures put in place to minimise risk. The manager demonstrated a commitment to monitoring practices in the home to ensure the health and safety of residents and staff in the home. Abbotsford Nursing Home DS0000062280.V279093.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X X STAFFING Standard No Score 27 X 28 3 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X X 2 X 2 Abbotsford Nursing Home DS0000062280.V279093.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15, 13 17 Sch 3 Requirement 1. The plan of care, where possible, must be drawn up with the involvement of the resident in a style accessible to the resident. Once agreed it must be signed by the resident whenever possible and/or their representative. 2. The responsible individual must ensure that an accurate record is kept of any nursing care provided to the resident, including a record of his/her condition and any treatment. (Previous timescale of 1/4/05 and 30/9/05 had not been met). 3. Requests from GP’s such as the monitoring of observations must be immediately implemented and recorded. 1. Evidence must be provided of the treatment of pressure sores i.e. pressure relieving equipment and evidence of pressure relief. Timescale for action 02/03/06 2 OP8 12 17 Sch 3 02/03/06 Abbotsford Nursing Home DS0000062280.V279093.R01.S.doc Version 5.1 Page 24 3 OP9 13 2. In order to promote and make proper provision for the health and welfare of residents’ referrals must be followed up in a timely manner to access specialist advice. 1. The policy’s and procedures 31/03/06 must be developed to include the issues identified in this report. 2. The record keeping surrounding the receipt of liquid medication must be reviewed. 3. In accordance with the Royal Pharmaceutical Guidelines the home must retain an up to date reference of current medication prescribed to each residnet. 4. The temperature of the room where medication is stored must be monitored and records kept. 5. All medication must be stored securely. 6. All medication dose changes must be documented and nurses must work within NMC guidelines. 1. A risk assessment of the grounds/garden must be completed with regard to the stored rubbish and the moss to the paving slabs. 2. The stored rubbish must be removed and the paving slabs appropriately cleared of moss. 4 OP19 13 31/03/06 5 OP27 18 The manager must ensure the dependency levels of the residents are regularly reviewed to ensure the staffing levels are sufficient to meet the assessed needs. 02/03/06 Abbotsford Nursing Home DS0000062280.V279093.R01.S.doc Version 5.1 Page 25 6 OP29 19 1. A full audit of all staff files must be conducted as a matter of urgency to ensure they contain all the information and documents specified in Schedule 2 of the Care Home Regulations 2001 and to ensure that all staff working at the home have a satisfactory enhanced CRB and POVA check. (Previous timescale of 31/1/05 and 31/7/05 had not been met). 2. Staff files must contain the original work permit and not a photocopy. 3. Evidence must be provided that any CRB disclosures are discussed and appropriate recordings made to document any investigation into the issue of concern. 02/03/06 7 OP30 18 8 OP36 18 1. Skills for Care have introduced 30/04/06 new requirements for staff induction and training. The manager must take account of the new requirements and review and revise their induction process. Evidence must be provided that 31/03/06 staff working at the home are appropriately supervised. (Previous timescale of 31/8/05 had not been met). 9 OP38 13 1. The list of remedial action required by the Fire Authority must be met. 2. The manager must develop a suitable fire risk assessment 01/04/06 Abbotsford Nursing Home DS0000062280.V279093.R01.S.doc Version 5.1 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 Refer to Standard OP1 Good Practice Recommendations 1. It is recommended that the Service User’s Guide be amended and re-printed rather than contain hand written amendments. 2. It is recommended that the Service User’s Guide contain information regarding the relevant qualifications and experience of the manager and staff. 2 OP8 1.It is recommended that all staff follow the same recoding procedure for wound redressing and progress reporting. 2. It is recommended that the manager gets resident/representative consent and takes photographs of pressure sores/wounds and record accurate measurements to track their progress. Abbotsford Nursing Home DS0000062280.V279093.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ 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 Abbotsford Nursing Home DS0000062280.V279093.R01.S.doc Version 5.1 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
