Inspection on 22/07/08 for Abbotsford Nursing Home

This inspection was carried out on 22nd July 2008.

CSCI found this care home to be providing an Good 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 Nursing Home 28/08/07

Abbotsford Nursing Home 11/07/06

Abbotsford Nursing Home 02/02/06

Abbotsford Nursing Home 05/07/05

Abbotsford Nursing Home 18/01/05

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOMES FOR OLDER PEOPLE Abbotsford Nursing Home 8/10 Carlton Road Whalley Range Manchester Lancashire M16 8BB Lead Inspector Geraldine Blow Unannounced Inspection 22nd July 2008 09:45 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Abbotsford Nursing Home DS0000062280.V364571.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 Nursing Home DS0000062280.V364571.R01.S.doc Version 5.2 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 Old age, not falling within any other category registration, with number (44) of places Abbotsford Nursing Home DS0000062280.V364571.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home with Nursing - Code N to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is: 44 Date of last inspection 28th August 2007 Brief Description of the Service: Abbotsford provides accommodation for a maximum of 44 residents. 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. 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 44 single bedrooms, 29 of which have en-suite facilities. There are 2 double rooms providing en-suite facilities. There are several lounge/dining rooms. The charges for fees range from £379.14 to £411.39 per week. Abbotsford Nursing Home DS0000062280.V364571.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 2 star. This means the people who use this service experience good quality outcomes. This report is based on information gathered by the Commission for Social Care Inspection (CSCI) and supporting information received in the Annual Quality Assurance Assessment (AQAA) submitted by the manager prior to this visit. Residents, staff and relatives were sent comment cards. At the time of this visit 5 resident, 3 staff and 2 relative comment cards had been received by CSCI. Some of their comments have been included in the body of this report. This visit was unannounced, which means that the manager and staff were not told that we would be visiting. This visit forms part of the overall inspection process and took place on Tuesday 22 July 2008. The opportunity was taken to look at all the core standards of the National Minimum Standards (NMS). This report is an overview of what the inspector found during the inspection. As part of the visit we (the commission) spent time examining relevant documents and files. We also spent time talking with the manager, several people living at the home, members of staff and a tour of the building was undertaken. Feedback was given to the manager during the course of this visit and on conclusion of the visit. The opportunity was taken to look at all the core standards of the National Minimum Standards (NMS). This inspection was also used to decide how often the home needs to be visited to make sure that it meets the required standards. What the service does well: Before a prospective resident is admitted to the home a pre-assessment of their needs is undertaken to make sure that the person’s needs can be met. Visitors are welcome in the home at any time and can visit in the resident’s own room or in any of the communal areas of the home. Both of the comment cards received from relatives indicated that the home always meets the needs of their family/friend, they are always kept up to date with important issues and the home gives the support or care that their relative/friend expects. Abbotsford Nursing Home DS0000062280.V364571.R01.S.doc Version 5.2 Page 6 Systems are in place to support people to raise any concerns they have and details of how to make a complaint are on display in the main reception. In the majority of returned comment card the residents indicated that they knew who to speak to if they were not happy and that staff do listen and act on what you say. There are a variety of activities that included regular visits from a variety of religious denominations. As stated in previous inspection reports the manager is very visible and approachable. She has an in-depth knowledge of all the residents and staff confirmed that she is very supportive and due to her the standards of care in the home continue to improve. Staff spoken to stated that there is a family atmosphere in the home and residents are encouraged to have choice around their daily lives. There is a choice of meals and the chef confirmed that if residents do not like what is on the menu then she will make any reasonable alternative. A Chinese chef is also employed to cater for the needs of Chinese residents. Residents spoken to stated that they can have drinks or snacks on request. What has improved since the last inspection? What they could do better: Although activities are being provided it is recommended that residents are consulted about the social and leisure activities that they enjoy and want to participate in so that the activities provided are what they want to do and enjoy doing. Abbotsford Nursing Home DS0000062280.V364571.R01.S.doc Version 5.2 Page 7 Although the standard of the care plans continues to improve it is recommended that they are developed on a more person centred approach and contain more details of the residents personal preferences. To ensure that residents are not put unnecessary risk it is recommended that following any safeguarding adults training a competency assessment is undertaken to ensure that staff have fully understood the training and know what to do in the event of an allegation of abuse being made. Although improvements continue to be made to the décor and furnishings of the home some areas still required improvement. To ensure that residents are not placed at any unnecessary risk the broken and cracked plastic bath panels must be replaced. To minimise any possible risk to residents it is recommended that all safety checks e.g. means of escape, water temperature testing and nurse call bells checks are consistently undertaken at the required intervals. 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 Nursing Home DS0000062280.V364571.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 Nursing Home DS0000062280.V364571.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems are in place to make sure that people’s needs are assessed before admission. EVIDENCE: Prospective residents are encouraged to visit the home before making a decision to move in. The majority of returned comment cards from people living at the home stated that they had received enough information about the home before moving in. A documented pre-admission assessment form is in use to ensure all residents assessed needs can be met prior to admission and the recommendation made in the previous inspection report that it includes an assessment of any specific religious and cultural needs had been met. Residents placed by the local authority had a care manager’s assessment of needs or a funded nurse assessment. An intermediate care service is not provided at Abbotsford Nursing Home. Abbotsford Nursing Home DS0000062280.V364571.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 &10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care needs of residents were being met EVIDENCE: A sample of care plans were seen and 3 residents were case tracked. Generally the care plans included the needs of the resident. Some areas of the care plan contained person centred information. For example one care plan clearly identified that the female resident only liked to wear trousers and another care plan had clear person centred instructions around the resident’s confusion. However other parts of the plans were vague and did not clearly set out the actions, which needed to be taken by staff to ensure that resident’s health and personal care needs are met. For example one care plan just stated that assistance was needed with hygiene but on discussion with the manager she clearly described exactly what help was required and what his personal preferences were. None of this information was included in his care Abbotsford Nursing Home DS0000062280.V364571.R01.S.doc Version 5.2 Page 11 plan, although the manager amended the plan of care during the course of this visit. It is recommended that all residents care plans are developed on a person centred approach and contain sufficient detail for staff to meet all residents identified needs and personal preferences. Care plans were seen to be reviewed on a monthly basis. However it was seen that some care plans were not always updated in accordance to the reviews. This was discussed with the manager during this visit. It is recommended that the plans of care are updated to reflect any changes in care needs identified in the monthly evaluation. The manager confirmed that she does not undertake formal audits of the care plans. To ensure that the individual plans of care meet the required standard it is recommended that the manager undertakes regular audits and feeds back directly to the key worker her findings. Appropriate risk assessments had been included and they had been regularly reviewed. Each resident was registered with a General Practitioner and evidence was seen of referrals to other specialised services according to individual assessed needs, for example, the Tissue Viability Nurse, Speech and Language Therapist and the Dietician. The records regarding medication were examined. There were no gaps in the recording of medication and medication had been signed into the home. A tablet count for several boxed medication was undertaken and found to be accurate. Surplus, unwanted or expired medicines were appropriately documented and their storage was discussed with the manager. There was no destruction kit available in the home, which is designed for the purpose of the disposal of Controlled Drugs (CDs). To ensure that unwanted or unused controlled drugs (CDs) are appropriately disposed of a destruction kit must be obtained for the disposal of CDs. From talking to residents and staff it appears that residents are encouraged to make choices around their daily lives. One staff comment was “the residents feel like our own family”. Abbotsford Nursing Home DS0000062280.V364571.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Some activities are provided and residents are able to maintain contact with family and friends. EVIDENCE: The manager described various activities that were provided. They included cream teas, hand massage, video afternoons, Pimms and strawberries afternoon during Wimbledon. In addition the manager confirmed that there are regular visits from a variety of religious denominations. However there was no documented evidence to support activities were being provided or that residents had been consulted about their personal preferences regarding activities. The majority of returned resident comment cards indicated that there are usually activities arranged by the home. One comment received in the resident comment card was “I like the singing and reading the newspaper”. It is recommended that people are consulted about the social and leisure activities that they enjoy and want to participate in and that it is clearly record in their care plan. It is also recommended that a record is kept of the activities provided and who attends. Abbotsford Nursing Home DS0000062280.V364571.R01.S.doc Version 5.2 Page 13 A copy of the menus were seen, which appeared to be varied and nutritionally balanced. The menus evidenced that a choice of meals is available and the chef confirmed that if residents did not want what was on the menu an alternative would be provided. The manager and chef confirmed that residents are asked at breakfast what they would like for their meals for that day. The home continues to employ the services of a Chinese Chef and Chinese meals are provided daily. Although Chinese food is provided there is not a menu for the Chinese meals. A recommendation has been made. The majority of returned residents comment cards indicated that they usually liked the food. One resident spoken to said that he food was “fine” and there was always a choice of meals. Discussions with the chef confirmed that cooked food is not being temperature probed prior to being served and a record is not being kept of all the food that is provided for residents. Recommendations have been made. Residents and staff spoken to confirmed that there is open visiting and visitors are made welcome. Comments received in the relative comment cards included “it’s a very happy home” and they are “very good with residents – nice atmosphere”. One of the cards indicated that the home help their relative keep in touch with you and the other cards indicated that the home usually did. Abbotsford Nursing Home DS0000062280.V364571.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems are in place to enable people to raise concerns and polices and procedures are in place to protect people from abuse. EVIDENCE: The complaint procedure was on display in the main reception area and the majority of returned resident comment cards indicated that they knew how to make a complaint. All the residents spoken to said they knew who to speak to if they had any worries or concerns. It was noted that the complaint procedure contained the previous contact address and phone number of CSCI, however following the inspection visit the manager confirmed that this had been updated. An internal quality audit evidenced that a lot of the Chinese residents knew who to speak to if they were not happy but they were not aware of the complaint procedure. Due to this the complaint procedure was translated into Chinese and all Chinese residents were given a copy. In addition the manager confirmed that the translated procedure was going to be displayed in the main reception. As at previous inspection visits the manager confirmed that she operates an open door policy and encourages people to raise any concerns they may have. No complaints have been received since the last visit either by the home or CSCI. Abbotsford Nursing Home DS0000062280.V364571.R01.S.doc Version 5.2 Page 15 There were policies and procedures in relation to Whistle Blowing and the protection of adults from abuse and there was a copy of the Manchester ‘No Secrets’ guidance. As some residents are funded from outside of Manchester it was recommended that the local ‘No Secrets’ guidance be obtained for those areas. Following the visit the manager confirmed that she had obtained a further two copies. The manager confirmed that Safeguarding Adults is covered during induction and is also covered in supervision sessions. However the training that is included in supervision has not been recorded. In order to evidence that staff have received appropriate training it is recommended that all in-house training is recorded and a competency assessment is undertaken to ensure that staff have fully understood the training and know what to do in the event of an allegation of abuse being made. Abbotsford Nursing Home DS0000062280.V364571.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Improvements continue to be made to the environment and generally a clean environment is provided. EVIDENCE: As already stated in this report further improvements have been made to décor and furnishings of the home and the manager confirmed that the refurbishment of bedrooms was continuing on a rolling programme. However during a tour of the building some arrears of concern were identified. For example the flooring in two of the bathrooms was ripped and was causing a trip hazard and the bath chair in one bathroom was seen to be split which could cause possible harm to a residents. However following the visit the manager confirmed that new flooring was to be laid in both bathrooms and a new bath chair had been ordered. Abbotsford Nursing Home DS0000062280.V364571.R01.S.doc Version 5.2 Page 17 During a tour of the building it was noted that the plastic bath panel on 2 baths were split and broken. To ensure that residents are not placed at any unnecessary risk these must be replaced. As identified in previous inspection reports the rear garden area was not suitable to be used by residents. However it was encouraging that plans were being made for the garden to be made safe and suitable for residents to use. It was noted that in many of the bathrooms the liquid soap dispensers were empty and there were bars of soap in use. This was discussed with the manager because as bars of soap do not minimise the risk of cross infection. Following the visit the manager confirmed that all soap dispensers were now full and all bars of soap have been removed. It was noted that the communal hoist was dirty. To prevent the risk of cross infection it is recommend that the hoist is thoroughly cleaned and is wiped down in-between resident use. Generally the home appeared to be clean and the majority of returned resident comment cards indicate that the home was usually clean and tidy. Abbotsford Nursing Home DS0000062280.V364571.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. 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. The number and deployment of staff available appeared sufficient to meet the needs of the residents. EVIDENCE: At the time of the site visit 40 residents were accommodated and the manager confirmed that on the morning shift there were two RGN’s and five or six carers on duty up to 2pm and then there were four carers. There were two RGN’s up to 5pm and then from 5pm there was one RGN and four carers and on night duty there was one RGN and 3 carers. The manager stated that 15 care staff are employed. Seven care staff have successfully completed NVQ Level 2 and three members of staff are currently working towards NVQ Level 2 and a further member of staff are working towards NVQ level 3. A sample of staff files were seen to see whether the required documentation was in place and the necessary checks had been made. The staff files looked at was for three members of staff who had been recruited since the last inspection. Some short falls were seen. For example one file did not have a photograph or proof of address and in another file there was no evidence that the last Abbotsford Nursing Home DS0000062280.V364571.R01.S.doc Version 5.2 Page 19 employer had been approached for a reference and references had been sent to a home address and their authenticity had not been checked. A recommendation has been made. The files looked at contained some photocopied documents and there was no evidence that the original documents had been seen. It is recommended that all photocopied documents are signed and dated to indicate that the original has been seen. In addition, in the files looked at there was no evidence that a set interview format had been used or that notes were taken. It is recommended that a set interview format is used and notes are taken during the interview process. None of the files seen contained a contract of employment. However following the visit the manager confirmed that all 3 members of staff had been issued with a contract. There was structured induction in place and the home had registered with Skills for Care. The manager confirmed that all new members of staff must complete induction and for their first few shifts they are not included in the staff numbers. The manager confirmed that the NMC website is checked bimonthly for nurse exclusion or suspension from the register and that nurses’ PIN numbers had not expired. External training for nurses and care staff appeared to rely on the training events offered at no cost to the care home. If free training could not be assessed, in house training is provided by the manager. Training DVD’s have recently been purchased, although not yet used. It is recommended that following any training staff should be assessed as competent to ensure they are able to provide the support that residents require to meet their needs and maintain their health and safety. There was an individual training record for staff and an overall training matrix but it they did not include details of in-house training attended. A recommendation has been made. Staff spoken to all said that the manger was very supportive with regard to training. Abbotsford Nursing Home DS0000062280.V364571.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is managed in the best interests of the people who live there. EVIDENCE: As detailed in previous inspection reports residents and staff benefit from a committed manager who is open and approachable. The staff spoken to all commented on how supportive she was to them and how much she cared about the residents. They said that due to the manager the standard of care continued to improve. Care staff are receiving regular supervision. However the sessions mainly focus on training and it is recommended that they be further developed to include all aspects of practice and the philosophy of the care in the home. Abbotsford Nursing Home DS0000062280.V364571.R01.S.doc Version 5.2 Page 21 As already mentioned in this report it is commendable that the home have achieved the Investors in People award. The manager confirmed that all the policies and procedures have been reviewed in May 2008. There are in a file, which is kept in the manager’s office, and staff can access on request. Quality questionnaires were sent out in May 2008 to review the quality of the service being provided. It was commendable that the results have been collated and are on display in the main reception. As already stated, due to results of the review the complaint procedure has been translated into Chinese and all Chinese residents have been given a copy. The manager confirmed that there are staff meetings approximately three times a year and residents meeting are held approximately twice a year, although minutes are not kept. Evidence was seen that the systems in place safeguarded resident’s financial interests, although during the visit it was recommended that a policy that clearly sets out the procedures for managing resident’s money be developed and implemented. In addition it was recommended that a written agreement be developed where residents give staff consent to undertake shopping for personal items. Following the visit the manager confirmed that both recommendations had been implemented. The information provided in the AQAA demonstrated that the home’s maintenance certificates and records were up to date. However it was noted that there was some gaps in the recording of some safety checks e.g. means of escape, fire alarms, nurse call bells and water temperature testing had not been undertaken at the frequency the manager stated they should be done. The manager confirmed that a new maintenance person had taken up post and it was her intention to ensure that he undertakes all the safety checks at the required intervals. To minimise any possible risk to residents it is recommended that all safety checks are consistently undertaken at the required intervals. Abbotsford Nursing Home DS0000062280.V364571.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 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 x x x x x x 3 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 3 x 3 3 x 2 Abbotsford Nursing Home DS0000062280.V364571.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13 (2) Requirement To ensure that unwanted or unused controlled drugs (CD’s) are appropriately disposed of a destruction kit for the disposal of CD’s must be obtained. To ensure that residents are not placed at any unnecessary risk the broken and split bath panels must be replaced. All staff files must include all the details listed in Schedule 2. Timescale for action 29/07/08 2. OP19 13 (4) (c) 29/07/08 3. OP29 19 and schedule 2 05/08/08 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 OP7 Good Practice Recommendations 1. It is recommended that all residents care plans are developed on a person centred approach and contain sufficient detail for staff to meet all residents identified needs and personal preferences. DS0000062280.V364571.R01.S.doc Version 5.2 Page 24 Abbotsford Nursing Home 2. To ensure that the individual plans of care meet the required standard it is recommended that the manager undertakes regular audits. 3. It is recommended that the plans of care are updated to reflect any changes in care needs identified in the monthly evaluation. 1. It is recommended that people are consulted about the social and leisure activities that they enjoy and want to participate in and clearly record this through their care plan. 2. It is recommended that a record be kept of the activities provided and who attends the activity. 1. It is recommended that a Chinese menu is implemented to evidence the Chinese meals provided. 2. To minimise any possible risk to residents it is recommended that all cooked food is temperature probed prior to being served. 3. It is recommended that the kitchen keep a record of all the food that is provided for residents. 4. OP18 It is recommended that any in house Safeguarding Adults training is documented and following the training a competency assessment is undertaken to ensure that staff have fully understood the training and know what to do in the event of an allegation of abuse being made. To prevent the risk of cross infection it is recommend that the hoist is thoroughly cleaned and is wiped down inbetween resident use. 1. It is recommended that a set interview format is used and notes are taken during the interview process. 2. It is recommended that written evidence be maintained that the original documentation has been seen, the date and by whom. 3. It is recommended that the authenticity of references are checked and are not sent to home addresses. 1. It is recommended that staff should be assessed as competent, following all training, to ensure they are able to provide the support that residents require to meet their needs and maintain their health and safety. DS0000062280.V364571.R01.S.doc Version 5.2 Page 25 2. OP12 3. OP15 5. OP26 6. OP29 7. OP30 Abbotsford Nursing Home 8. 9. OP33 OP36 2. It is recommended that the individual training and development record and the overall training matrix include all training attended including in house training. It is recommended that minutes are kept of any resident or staff meetings. It is recommended that the supervision sessions are further developed to include all aspects of practice and the philosophy of the care in the home. To minimise any possible risk to residents it is recommended that all safety checks are consistently undertaken at the required intervals. 10. OP38 Abbotsford Nursing Home DS0000062280.V364571.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU 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 Nursing Home DS0000062280.V364571.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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