Inspection on 28/08/07 for Abbotsford Nursing Home

This inspection was carried out on 28th August 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Abbotsford Nursing Home 22/07/08

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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Abbotsford Nursing Home 8/10 Carlton Road Whalley Range Manchester Lancashire M16 8BB Lead Inspector Geraldine Blow Unannounced Inspection 28th August 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Abbotsford Nursing Home DS0000062280.V342454.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.V342454.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 Learning disability (1), Old age, not falling registration, with number within any other category (40), Physical of places disability (3) Abbotsford Nursing Home DS0000062280.V342454.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. 7. 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. 7th February 2007 8. Date of last inspection 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 3 lounge/dining rooms. The charges for fees range from £373.54 to £404.10 per week. Abbotsford Nursing Home DS0000062280.V342454.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report is based on information gathered by the Commission for Social Care Inspection (CSCI) since the last inspection on 7 February 2007 and supporting information received in Annual Quality Assurance Assessment (AQAA) submitted by the manager prior to this visit. Residents and General Practitioners (GPs) were sent comment cards. Twelve resident comment cards were received, the residents themselves completed 5 of those and 7 were completed with the help of staff. One GP comment card was received by CSCI. This unannounced visit forms part of the overall inspection process and took place on Tuesday 28 August 2007. 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. As part of the visit time was spent examining relevant documents and files, talking with the home’s manager, several people living at the home, some members of staff and a tour of the building was undertaken. What the service does well: A pre-admission assessment of needs is carried out before a resident is admitted to the home to make sure that the home can meet all of their needs. Staff were seen to be kind and patient with residents when carrying out their duties. The atmosphere felt relaxed and staff and residents were seen to have good relationships. All staff spoken to said that residents are encouraged to make their own choices about their day-to-day lives. Where able, residents were seen to be freely walking around the home. There continues to be a choice of meals at each mealtime and the returned comment cards indicated that the food was nice and they confirmed that a choice was available. A Chinese chef is employed by the home and Chinese meals are available every day. A wide range of fresh fruit and vegetables are available daily. The home has an open visiting policy, which was confirmed by the staff spoken to. Systems were in place to support residents or visitors to make a complaint and all returned comment cards, with the exception of 1, stated that they knew how to make a complaint. Abbotsford Nursing Home DS0000062280.V342454.R01.S.doc Version 5.2 Page 6 The manager and staff in the home had a good awareness of the importance of offering appropriate activities. Evidence was seen of various activities, some of which included outside entertainers such as ‘musical memories’, Chi Gong, which is a form of Chinese exercise, a dragon festival, Wimbledon special with strawberries and cream and a Chinese tea party. The returned comment cards supported the evidence seen that activities are provided. Policies and procedures were in place to protect residents from abuse and the majority of staff had received appropriate awareness training. As reported in previous inspection reports the manager is very visible and approachable. She has an in-depth knowledge of all the residents and during the inspection she stopped and spoke with any resident that she passed. The residents and staff benefit from her open door policy and staff spoken to said that she was very caring and supportive. What has improved since the last inspection? What they could do better: Abbotsford Nursing Home DS0000062280.V342454.R01.S.doc Version 5.2 Page 7 A pre-admission assessment of needs is carried out before a resident is admitted to the home to make sure that the home can meet their needs. However it is recommended that the assessment include an assessment of any specific religious and cultural needs. Although as already stated in this report activities were being provided, it is recommended that some time is spent talking to residents or their families to find out what their individual interests are and keeping records of the activities that residents attend. Care plans were generally detailed and informative and some were person centred which included details of individual preferences. It is recommended that all care plans are further develop on this person centred approach. Although improvements were seen to the décor and furnishings of the home some areas still required improvements. For example, some bedroom and dining room furniture were showing signs of wear and tear and bedroom doorframes were chipped and marked. Also as seen at the last inspection visit, there was an old chest freezer and an old fridge freezer stored on the rear patio area. These items have the potential to put residents using the patio area at risk and therefore must be removed. It was disappointing that the recommendation made in the last inspection report that the rear conservatory be cleaned and made attractive and possibly made accessible for residents to use via the patio area had not been met. A requirement was made in the last inspection report that due to a problem with the temperature of the water being delivered regular water temperature testing must be carried out. This requirement had not been met. To ensure the comfort and safety of residents and staff this requirement has been made again in this report. Not all of the maintenance certificates were in place for example portable appliance testing or a certificate of the disposable for soiled waste. There is a Chinese-speaking member of staff on duty every day but there is not always one on night duty. It is recommended that the staff rotas are reviewed in an attempt to have a Chinese speaking member of staff on duty 24 hours a day 7 days a week. 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.V342454.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.V342454.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 (Standard 6 intermediate care is not provided at Abbotsford Nursing Home). Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service The home undertakes an assessment of prospective residents’ care needs prior to their admission. EVIDENCE: A pre-admission assessment form is in use to ensure that prospective residents are only admitted on the basis of a full assessment and for those residents who are referred through Care Management arrangements a copy of the Care Management Assessment is obtained before admission is arranged. Following the pre-admission assessment the home confirms in writing to the prospective resident that the home is able/not able to meet their assessed needs. This is seen as good practice. However it is noted that the pre-admission assessment did not include an assessment of any specific religious and cultural needs. A recommendation has been made to address this. Abbotsford Nursing Home DS0000062280.V342454.R01.S.doc Version 5.2 Page 10 Where possible, prospective residents and their family/representative are encouraged to view the home prior to making a decision about admission. The home does not provide an intermediate care service. Abbotsford Nursing Home DS0000062280.V342454.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service Some shortfalls were identified in ensuring that the health care needs of residents were being met. EVIDENCE: Three residents were case tracked during this inspection visit and their care files were examined. Each resident had an individual plan of care which had been reviewed on a monthly basis. Some areas of the care plans were person centred and included individual preferences for example “likes to have her colouring book and crayons to hand”. However others parts were quite vague and did not clearly set out the individualised actions or personal preferences which needed to be taken by staff to ensure that residents’ individual health and personal care needs are fully met. It is recommended that that all residents care plans are developed on a person centred approach. During discussion with the manager it was evident that one resident had some communication difficulties but there was no care plan to address this need. This could have the potential to put residents at risk. Abbotsford Nursing Home DS0000062280.V342454.R01.S.doc Version 5.2 Page 12 Risk assessments had been included, however it was noted that for residents who had a bed rail in situ that the use of the bed rail had not been risk assessed. There was an “audit of detachable bed rails” in place, which is seen as good practice, but not a risk assessment relating to the use of bed rails. The manager did have a risk assessment document but it had not been implemented. To ensure the safety of residents the risk assessment must be implemented. The files were found to be user friendly and easy to use. There was a day and night record of the care provided, however they were of varying standards. Some entries were detailed and informative, however some entries were vague and lacked detail. In order to ensure that all assessed needs are being met it is recommended that an accurate record of care provided should be kept. Residents were registered with local General Practitioners and had access to visiting healthcare professionals e.g., Dietician, Chiropody, Dentistry and Ophthalmology. This ensured residents were in receipt of appropriate health services necessary to support their individual health care needs. Medication Administration Record Sheets (MAR) were examined. It was only day 2 of week 1 of the cycle and therefore the records available were minimal. From the evidence available all medication had been signed into the home and the medication given had been signed for. It was seen as good practice that 2 nurses had the responsibility for the administration of medication. A requirement was made in the previous inspection report that hand written entries on the MAR sheet must be signed for by the person making the entry. This requirement had not been met and has been reiterated in this report. Since the last inspection a record sheet, which included the specific instructions from the Speech And Language Therapist (SALT), with regard to the thickness of fluids for individual residents, had been developed and implemented. This is seen as good practice. On the MAR examined it did not cross reference to where this record was kept but the deputy manager said that was an error and was usually clearly documented. All returned medication is documented in the returns book and is then signed for by the person collecting them. It is recommended that 2 staff witness and sign for the disposal of waste medication. It was noted that medication with a limited life had the date of opening documented so ensuring out of date medication is not given to residents. It was encouraging that the manager undertook a monthly audit of all loose medication and records are kept. This is seen as good practice. From observations and talking to staff at the home it appeared that residents privacy and dignity was respected. Abbotsford Nursing Home DS0000062280.V342454.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. 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 were provided and residents were able to maintain contact with family and friends. EVIDENCE: The manger said that since the last inspection the post of activity co-ordinator had been advertised but they had been unable to fill the post. The post is due to be re-advertised in the near future. However evidence was seen of a variety of activities that had taken place and the manager said that various 1:1 activities such as taking residents to the shops were also undertaken. It was encouraging that a multi-cultural day was in the planning process for October 2007 where a variety of national dishes will be available for residents and their visitors to sample. The feedback from the comments cards indicated that residents were happy with the activities provided. The pre-admission document does have a small section to access the hobbies and interest of residents and in the documents looked at this section had been completed. However it is recommend that when an activity co-ordinator is employed some time is spent gathering information about residents’ individual Abbotsford Nursing Home DS0000062280.V342454.R01.S.doc Version 5.2 Page 14 interests and life history to help ensure that daily living and activities are flexible and suited to individual preferences and capacities. It is also recommended that a record be kept of the activities undertaken by residents. The manager said that the home facilitated open visiting and visitors could be received in the residents’ own room or any of the communal areas of the home. Discussions with staff confirmed this. From speaking to staff it appeared that residents are able to exercise choice and control over their lives and that residents are encouraged to bring personal possessions into the home. A varied diet, which is nutritionally balanced with adequate supplies of fresh fruit and vegetables is provided and alternatives to the main meal are available. This was supported by the received comment cards and confirmed by staff spoken to. The home employs the services of a Chinese cook and Chinese meals are provided daily provided. Staff confirmed that snacks and drinks are available on request. Food stocks were seen in sufficient amounts and were appropriately stored off the floor. As required in the previous inspection report food stored in the fridge had been covered and dated. Abbotsford Nursing Home DS0000062280.V342454.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. 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. The home encouraged and supported people to raise their concerns and complaints and had the policies, procedures and systems in place to protect residents from abuse. EVIDENCE: As identified in the previous inspection report there was a complaint procedure, which was on display in the main reception area, and a copy was included in the Service User Guide, which every resident had been given. All returned resident comment cards completed by the residents, with the exception of 1, identified that they knew how to make a complaint. The manager said that she operates an open door policy and residents, relatives/visitors, staff and visiting professionals to the home are encouraged to raise any concerns or complaints with her. There is a complaint file with details of any complaints, any investigation, including staff statements, copies of any correspondence and an outcome of the complaint. There were policies and procedures in relation to protection of adults from abuse and Whistle Blowing. The home had a copy of the Manchester MultiAgency Policy on the Protection of Vulnerable Adults from Abuse. The manager was able to accurately describe the actions to be taken in the event of an allegation of abuse and Protection of Vulnerable Adults (POVA) awareness training was being provided on an ongoing basis. Staff spoken to confirmed that they had received the training. Abbotsford Nursing Home DS0000062280.V342454.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 Further improvements had been made to the homes décor in order to provide clean, comfortable surroundings for residents. EVIDENCE: As already stated in this report further improvements had been made to the décor and furnishings within the home. Although improvements had been made some areas were still in need refurbishment. For example several items of bedroom and dining room furniture and some paintwork and doorframes were seen to be showing signs of age and general wear and tear. The manager said that the internal refurbishment of the home was continuing on an ongoing basis. Abbotsford Nursing Home DS0000062280.V342454.R01.S.doc Version 5.2 Page 17 Generally the home was clean and comfortable for residents. There were 5 returned comment cards completed by the residents and 4 of those stated that the home was always clean and fresh and 1 indicated that is was usually clean and fresh. One comment received was “the cleaners always do a good job.” As referenced in the previous report the garden area was not being utilised to its full potential and the unused chest freezer and fridge freezer were still being stored on the rear patio. These items have the potential to put residents at risk and must be removed. Since the last inspection visit the clinical waste and general rubbish bins had been enclosed by a wooden fence on 3 sides only. On the day of this visit the bins were full to overflowing and were on full view of the garden area. To ensure that these do not pose a risk to residents is recommended that these are stored in a fully enclosed area. In one bathroom viewed there were a number of toiletries on the windowsill for example shampoo, 2 bars of soap, shaving foam and various prescribed creams for residents. The manager said that each resident has a basket containing their own personal toiletries that is taken to the bathroom with them and in this instance the baskets had not been returned to their bedroom after use. The manger gave assurances that she would speak to the staff and remind them of the importance of returning all toiletries immediately after use after use. In the same bathroom the pipe work leading from the parker bath was exposed. To ensure the health and safety of residents and staff these must be enclosed. Abbotsford Nursing Home DS0000062280.V342454.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 good. This judgement has been made using available evidence including a visit to this service. The number and skill mix deployment of staff available appeared sufficient to meet the needs of the residents. EVIDENCE: At the time of this visit 39 residents were accommodated. Twenty-six residents had been assessed as requiring nursing care and 13 residents had been assessed as requiring personal care only. From direct observation and from reviewing the duty rota it appeared that staff were employed in sufficient numbers to meet the assessed needs of the residents. From the 5 returned residents’ comment cards completed by the residents 3 stated that staff are always available when you need them and 2 said there were usually enough staff. The manager said that there is always a Chinese-speaking member of staff on the morning and afternoon shift but not always on the night shift. This could have the potential to isolate the Chinese residents who do not speak English. It is recommended that staff rotas are reviewed in an attempt to have a Chinese speaking member of staff on duty 24 hours a day 7 days a week. Abbotsford Nursing Home DS0000062280.V342454.R01.S.doc Version 5.2 Page 19 Seventeen care staff are employed, 11 of those have achieved NVQ Level 2, 1 member of care staff is currently under taking NVQ Level 2 and 2 care staff have recently registered to undertake the training. There was a structured induction in place, which the manager said had recently been updated to include the recommendations made by Skills for Care though it had not yet been implemented. In addition the home had registered with Skills for Care. This is seen as good practice. Since the last inspection visit the manager had implemented an individual training record for all staff and evidence was seen that training was being provided on an ongoing basis. However it was noted that the records were not up to date. It is recommended that they are kept up to date in order to demonstrate that staff have received the necessary training to provide the support that residents require to meet their needs and maintain their health and safety. A random selection of staff files were examined and contained the appropriate documentation as required by Schedule 2 of The Care Homes Regulations 2001. The manager said that a 6 monthly check is made with the NMC, using a caller code, to check for PIN number expiry dates and any nurses who may have been suspended or excluded from the register, although for suspension no records are kept. It is recommended that the check is undertaken on a more frequent basis and records are kept. Abbotsford Nursing Home DS0000062280.V342454.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 adequate. This judgement has been made using available evidence including a visit to this service Not all the systems and procedures were in place to promote the health, safety and welfare of the residents and staff. EVIDENCE: As identified in previous inspection reports the residents and staff benefit from a committed manager who operates an open management style and encourages residents, visitors 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. The staff spoken to said they were happy with the way the home is managed Abbotsford Nursing Home DS0000062280.V342454.R01.S.doc Version 5.2 Page 21 and felt that they were very well supported by the manager and the residents receive excellent care. As required in the previous inspection report staff are now receiving formal supervision sessions. Since the previous inspection visit the manager has distributed quality assurances questionnaires to residents, their families and visiting professionals. She in now in the process of collating the results in order to produce a quality report. The results from the quality questionnaires sent out identified that people were not aware of the complaint policy available at the home. It was encouraging that the manager had addressed the issue by sitting with all with admissions and their families to go through the procedure and points out where it is on display in the home and where it is in the Service User Guide. Where possible Social Services or residents family have the responsibility for residents finances. Where this is not possible the homes administrator has responsibility for managing the personal allowance. There is a clear and transparent system for managing and recording the personal finances of the residents. All transactions and documentation was available for inspection. Evidence was provided in the Annual Quality Assurance Assessment (AQAA) submitted by the manager prior to this visit that some of the home’s maintenance certificates and records were up to date. However there was no evidence of portable electrical equipment testing or soiled waste disposal certificate. In addition although there were record sheets to record weekly tests of the nurse call bell systems this had not been undertaken. These shortfalls have the potential to put residents at risk. It was of some concern that evidence could not be provided that the requirement made in the previous inspection report regarding the need to undertake regular water temperature testing had been met. The previous inspection visit highlighted that the temperature of water delivery was not within the recommended temperature; it ranged from 25.4oC to 45.4oC. The manager said that the plumber had been but they were still experiencing some problems with the temperature delivery. To ensure the health and safety of residents and staff the requirement has been reiterated in this report. The records relating to the fire safety checks appeared to have been regularly undertaken. However the records were not clear and it was difficult to understand the information recorded. It is recommended that clear and concise records are kept. Abbotsford Nursing Home DS0000062280.V342454.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 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 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 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 2 Abbotsford Nursing Home DS0000062280.V342454.R01.S.doc Version 5.2 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 (1) 13 (4) (c) Requirement 1. To ensure that all residents care needs are fully met a care plan must be implemented for all health, social and personal care needs 2. To ensure the health and safety of residents risk assessments relating to the use bed rails must be implemented to adequately assess the risk of the use of the bed rail. Hand written entries on the MAR sheet must be signed by the person making the entry. Timescale for action 01/10/07 2. OP9 13 (2) 29/08/07 3. OP19 23 (2) (o) 13 (4) (c) (Previous timescale of 26/02/07 had not been met). 1. To ensure the health and 01/10/07 safety of the residents the unused freezer and fridge freezer stored on the rear patio must be removed. 2. To ensure the health and safety of staff and resident the exposed pipes leading from the parker bath must be enclosed. Abbotsford Nursing Home DS0000062280.V342454.R01.S.doc Version 5.2 Page 24 4. OP38 13 (2) (c) 1. To ensure the health and safety of residents and staff regular water temperature testing must be undertaken and appropriate action taken if it is not within the recommended guidelines. (Previous timescale of 12/7/06, 26/2/07 and 26/2/07 had not been met). 2. To ensure the health and safety of residents accommodated and the staff working at the home all appropriate tests and services must be undertaken for all equipment and services within the home. 29/08/07 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. Refer to Standard OP3 OP7 Good Practice Recommendations It is recommended that the pre- admission assessment include an assessment of any specific religious and cultural needs. 1. It is recommended that all residents care plans are develop on a person centred approach. 2. It is recommended that an accurate daily record of the care provided is to be kept. It is recommended that 2 staff witness and sign for the disposal of waste medication. 1. It is recommend that when an activity co-ordinator is employed some time is spent gathering information about residents’ individual interests and life history to help ensure that daily living and activities are flexible and suited to individual preferences and capacities. 3. 4. OP9 OP12 Abbotsford Nursing Home DS0000062280.V342454.R01.S.doc Version 5.2 Page 25 5. 6. 7. 8. OP19 OP26 OP27 OP29 9. OP30 10. OP38 2. It is recommended that a record be kept of the activities undertaken by residents. It is recommended that the general waste and clinical waste bins are stored in a fully enclosed area. It is recommended that after use all toiletries are immediately taken back to resident’s bedrooms to ensure that communal toiletries are not used. It is recommended that staff rotas are reviewed in an attempt to have a Chinese speaking member of staff on duty 24 hours a day 7 days a week. It is recommended that records are kept of the checks made with the NMC for PIN number expiry dates and any nurses who may have been suspended or excluded from the register. It is recommended that the individual training records are kept up to date in order to demonstrate that staff have received the necessary training to provide the support that residents require to meet their needs and maintain their health and safety. It is recommended that clear and concise records are kept relating to the fire safety checks. Abbotsford Nursing Home DS0000062280.V342454.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.V342454.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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