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Inspection on 05/07/05 for Abbotsford Nursing Home

Also see our care home review for Abbotsford Nursing Home for more information

This inspection was carried out on 5th July 2005.

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

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

What has improved since the last inspection?

Since the last inspection a new manager has been appointed. Staff were very positive about the manager. One member of staff said "that the manager was approachable, she comes out of the office and is involved in hands on care," she also said that the manager "checks up on standards in the home and makes sure that residents are cared for properly." Other staff comments include "the new manager if firmer about standards in the home but is lovely, she is nice even when she is telling you, you have done something wrong". Some refurbishment and redecoration has taken place since the last inspection. The ground floor corridor, the large lounge and what was previously the dining room has been redecorated. New carpets have been fitted on the ground floor and some reorganisation of the communal areas has taken place. The home now provides 3 lounge/dining rooms. The home employs 3 members of staff who speak Cantonese and is prioritising recruitment of Chinese care workers.

What the care home could do better:

Due to the areas of serious concern identified regarding medication the home must action all the issues raised by the Pharmacy Inspector to ensure the safety of residents. All of the resident must be given a copy of an up to date Service User Guide. The manager is in the process of reviewing and updating the residents` plans of care. All residents care plans must be reviewed, updated and include detailed risk assessments to ensure all care needs are met. The home must ensure that all wheelchairs are cleaned and fit for use by residents. Although refurbishment are taking place some of the furnishing and fittings, particularly in service users bedrooms were of a poor standard and in need of cleaning, repair or replacement. The home must complete a full audit of the home to prioritise the areas in most need of attention. Since the last inspection some activities have taken place. However one resident said "we don`t do much just watch telly, at the other home I was atwe played bingo and had a quiz, that was good. "I would like to do that here." The home should consider having a designated activity co-ordinator that structures and plans activities with the residents. The home must develop policies and procedures to protect residents from abuse and they must provide training to all staff so that they would know what to do if there was an allegation of abuse. Before any staff start working at the home checks must be carried out to make sure they are safe to work with the residents.

CARE HOMES FOR OLDER PEOPLE Abbotsford Nursing Home 8/10 Carlton Road Whalley Range Manchester M16 8BB Lead Inspector Geraldine Blow Unannounced 05 July 2005 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 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 F55 F05 s62280 Abbotsford V236823 D050705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Abbotsford Nursing Home Address 8/10 Carlton Road Whalley Range Manchester M16 8BB 0161 226 8822 Telephone number Fax number Email 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 Mr Joseph Heifetz Care home with Nursing (N) 44 Category(ies) of Old age, not falling within any other category registration, with number (OP) (40) of places Physical disability (PD) (3) Learning disability (LD) (1) Abbotsford Nursing Home F55 F05 s62280 Abbotsford V236823 D050705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. The maximum number of service users accommodated shall be 44. 2. Nursing care is provided for a maximum of 34 older people aged over 60 years. 3. 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. 4. 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. 5. 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. 6. 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. 7. As detailed in the Statement of Purpose the home must continue to provide the appropriate level of services to met the specific social, cultural and and religious needs of the Chinese service users accommodated at the home. 8. The service must employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. Date of last inspection 18 January 2005 Abbotsford Nursing Home F55 F05 s62280 Abbotsford V236823 D050705 Stage 4.doc Version 1.40 Page 5 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.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 F55 F05 s62280 Abbotsford V236823 D050705 Stage 4.doc Version 1.40 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was an unannounced inspection, conducted by 2 inspectors, which took place over the course of 4½ hours on Tuesday 5th July 2005. During the course of the inspection time was spent talking to the homes manager, residents and members of staff to find out their views of the home. Time was spent examining records, documents and residents files. A tour of the building was also conducted. Since the last inspection the home has appointed a new manger and there was evidence that she was working hard to develop the service. Not all of the requirements from the previous inspection had been addressed and they have been incorporated into this report. Since the last inspection the Commission for Social Care Inspection (CSCI) have received 2 complaints. During the course of investigating these complaints a number of serious concerns were identified, the CSCI Pharmacy Inspector has carried out a full audit of medication and a Notice of Enforcement was issued to the home in relation to medication. A separate report has been produced containing her findings. This report is available on request. In addition since the last inspection the home has received one allegation of abuse. During this inspection only a selection of the key National Minimum Standards were assessed therefore in order to gain the full picture of how the home meets the needs of residents this report should be read with the previous and any future reports. What the service does well: The home assessed prospective residents care needs before their admission to the home to ensure their needs can be met. A number of positive comments were given to the inspectors by the residents about living at the home. One resident said “the staff are good, they have a laugh and a joke with you”, another resident said that she was regularly visited by her son and the staff made him feel very welcome. One resident said, “this is a lovely place to be in – you can’t call it”. Abbotsford Nursing Home F55 F05 s62280 Abbotsford V236823 D050705 Stage 4.doc Version 1.40 Page 7 Meals appeared to be varied and wholesome. One resident said that “meals are very good” and another resident told the inspector that “the food is very good”. The home accommodates some Chinese residents and Chinese food is provided for these residents. What has improved since the last inspection? What they could do better: Due to the areas of serious concern identified regarding medication the home must action all the issues raised by the Pharmacy Inspector to ensure the safety of residents. All of the resident must be given a copy of an up to date Service User Guide. The manager is in the process of reviewing and updating the residents’ plans of care. All residents care plans must be reviewed, updated and include detailed risk assessments to ensure all care needs are met. The home must ensure that all wheelchairs are cleaned and fit for use by residents. Although refurbishment are taking place some of the furnishing and fittings, particularly in service users bedrooms were of a poor standard and in need of cleaning, repair or replacement. The home must complete a full audit of the home to prioritise the areas in most need of attention. Since the last inspection some activities have taken place. However one resident said “we don’t do much just watch telly, at the other home I was at Abbotsford Nursing Home F55 F05 s62280 Abbotsford V236823 D050705 Stage 4.doc Version 1.40 Page 8 we played bingo and had a quiz, that was good. “I would like to do that here.” The home should consider having a designated activity co-ordinator that structures and plans activities with the residents. The home must develop policies and procedures to protect residents from abuse and they must provide training to all staff so that they would know what to do if there was an allegation of abuse. Before any staff start working at the home checks must be carried out to make sure they are safe to work with the residents. 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 F55 F05 s62280 Abbotsford V236823 D050705 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Abbotsford Nursing Home F55 F05 s62280 Abbotsford V236823 D050705 Stage 4.doc Version 1.40 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 standard(s) 1, 3 & 5 The home undertakes an assessment of prospective residents care needs prior to their admission. Their relatives/friends are able to visit the home before making the decision to stay. EVIDENCE: A requirement was made at the previous inspection that all residents must be provided with an up to date copy of the Service User Guide. This requirement had not been met and has been reiterated in this report. The manager advised the inspectors that she undertakes a pre-admission assessment of prospective residents to ensure that the home could meet all of their assessed needs. The assessment included the involvement of the prospective resident, his/her representatives and any relevant professionals. Following the assessment the home then sends a letter of confirmation to the prospective resident that the care home is able to meet their assessed needs. Where possible, prospective residents and their family/representatives were encouraged to view the home prior to making a decision about admission. Abbotsford Nursing Home F55 F05 s62280 Abbotsford V236823 D050705 Stage 4.doc Version 1.40 Page 11 For residents who are referred through Care Management arrangements the home obtains a summary of the Care Management Assessment prior to admission. Abbotsford Nursing Home F55 F05 s62280 Abbotsford V236823 D050705 Stage 4.doc Version 1.40 Page 12 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 standard(s) 7, 8 & 10 The needs to improve its documentation to ensure residents health care needs are fully met. These shortfalls have the potential to place residents at risk. The CSCI Pharmacist Inspector has produced a separate report in relation to medication due to a number of shortfalls at the home. EVIDENCE: The manager was in the process of reviewing, updating and implementing new documentation for all of the care plans. Due to this a thorough inspection of the care plans will be conducted at the next inspection once the new system has been fully implemented. A small number of the updated plans were inspected and were found to be much improved, however a number of issues were identified and discussed with the manager. Risk assessments were observed to be included within the individual plan of care but they were limited and lacked detail. One resident had bed rails in situ and a risk assessment had not been completed although consent had been obtained for their use. Not all of the bed rails in situ were accompanied by the use of bumpers. Limited evidence was seen of the involvement of the resident/representative involvement with the drawing up of the plan of care. Abbotsford Nursing Home F55 F05 s62280 Abbotsford V236823 D050705 Stage 4.doc Version 1.40 Page 13 The daily nursing report was vague and provided little indication of the actual care given. It was encouraging to note, during discussions with staff, that the manager was involving them in the development of the care plans. Equipment necessary for the promotion of tissue viability and the prevention or treatment of pressure sores was viewed during the inspection. The plans of care that were inspected had documented which pressure-relieving mattress was in use for individual residents. The home must ensure that evidence is provided that care staff maintain the personal and oral hygiene of each resident and wherever possible support the residents own capacity for self-care. The home appeared to treat residents with respect and dignity. Examples were seen of staff talking with residents in a respectful and courteous manner. Privacy and dignity had been incorporated into the plans of care Abbotsford Nursing Home F55 F05 s62280 Abbotsford V236823 D050705 Stage 4.doc Version 1.40 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 & 15 Social activities were limited and there was no evidence of consultation with residents. The menus inspected appeared to offer a nutritious and healthy diet. EVIDENCE: The manager had recently organised an outside entertainer and a clothing party had been arranged for the end of July. One member of staff told the inspector that she did manicures for the residents and spent time doing their hair. She also said that the manager encouraged staff to sit on talk to residents. However, there was no evidence that residents had been consulted regarding their preference regarding social activities. A limited social history had been recorded on admission although this did not include hobbies and interests. The menu inspected had been developed on a 4-week rota system, although the manager said this was currently under review. Specially prepared Chinese food is provided for the evening meal on a daily basis. Residents spoken to spoke highly of the meals provided. The home did not have a menu on display although the chef told the inspector that she consults with residents on a daily basis and alternative meals are provided on request. Abbotsford Nursing Home F55 F05 s62280 Abbotsford V236823 D050705 Stage 4.doc Version 1.40 Page 15 The home provided 3 dinning areas and most residents were observed to have their lunch in one of the dining areas. Abbotsford Nursing Home F55 F05 s62280 Abbotsford V236823 D050705 Stage 4.doc Version 1.40 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 & 18 The home had a complaints procedure but this was not known to the residents. The homes policies and procedures required updating to ensure residents are protected from abuse. EVIDENCE: The home had a complaints procedure that was on display on the main corridor although not all residents had been given a copy. Since the last inspection, the Commission has received 2 complaints and 1 allegation of abuse had been made. As a direct result of the complaints made the Pharmacist Inspector is working closely with the home on a number of serious concerns relating to the management of medication. The manager was aware of the need to keep a record of all complaints made that includes details of investigations and any action taken. The manager had a Whistle Blowing policy and a copy of the Manchester Multi Agency Policy for the Protection of Vulnerable Adults from Abuse. However the policies and procedures required reviewing and updating. Staff spoken to were not familiar with the home’s policies and procedures around the Protection of Vulnerable Adults and had not received training in the action to be taken in the event of an allegation of abuse. Abbotsford Nursing Home F55 F05 s62280 Abbotsford V236823 D050705 Stage 4.doc Version 1.40 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 standard(s) 19, 22, 25 & 26 Some improvements in the décor had been made but there were still areas of the home that did not provide, clean comfortable surroundings for residents. EVIDENCE: The location and layout of the home was suitable for its stated purpose. Access to the home was via steps or a wheelchair ramp to the front of the property. A passenger lift offered access to all of the home’s floors. The garden area was accessible to residents and a conservatory had been erected to the rear of the property. However further building work was required before the conservatory could be used by residents. Since the last inspection, improvements could be seen to the ground floor of the home. Extensive re-painting had been completed and new carpets had been fitted. The layout of the lounges and dining room had been changed. The home now provided 3 lounge/dining rooms. Due to these changes this area of the home felt cleaner, lighter and more welcoming. Abbotsford Nursing Home F55 F05 s62280 Abbotsford V236823 D050705 Stage 4.doc Version 1.40 Page 18 The manager said that 5 bedrooms had been measured for new carpets and bedrooms would be decorated when they became empty. It is acknowledged that refurbishment/redecoration is taking place and the decorators were seen on the day of inspection. However, on a tour of the building many areas of the home were identified to be in need of attention. Bedroom furniture was dirty and substandard. The majority of the bedrooms required re-painting in particular the wall to which the bed was positioned in room 214. The bath panel in bathroom next to room 203 required replacing. The home must conduct a full audit of the home to identify the areas in most urgent need of attention. It was noted that a large number of wheelchairs were dirty and encrusted with food. A large number of the chairs did not have footrests and had not been personalised for individual use. During a tour of the building it was noted that sluice doors were not kept locked, which posed a potential risk to residents. A number of window restrictors viewed were not appropriate as they were small thin chains which could be easily broken and the window in room 306 did not have a window restrictor. Abbotsford Nursing Home F55 F05 s62280 Abbotsford V236823 D050705 Stage 4.doc Version 1.40 Page 19 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 & 30 The numbers and skill mix of staff appeared to be sufficient to meet the needs of the residents. However, the home’s recruitment procedures must be reviewed so as to protect and safeguard the residents. EVIDENCE: At the time of the inspection the home accommodated 36 residents i.e. 21 residents assessed as requiring nursing care and 15 residents assessed as requiring personal care only. Three residents were in hospital. The numbers and skill mix of the staff, at the time of inspection appeared to be sufficient to meet the needs of the number of residents accommodated. However, the dependency levels of the residents assessed, as requiring personal care only was unclear. To accurately assess the care hours required the home must constantly review the dependency levels of the residents. A sample of staff files were inspected during the inspection. These files did not contain all the information listed in Schedule 2 of The Care Home’s Regulations 2001. There was no evidence that newly appointed staff had undertaken induction training. In addition there was no evidence that staff had received appropriate/mandatory training. It is recommended that all staff have an individual training and development plan to evidence trainging received. Abbotsford Nursing Home F55 F05 s62280 Abbotsford V236823 D050705 Stage 4.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 36 & 38 The newly appointed manager appears competent and experienced to run the home. However, some areas of practise did not promote the health, safety and welfare of residents. EVIDENCE: During discussions with the manager and several members of staff it was evident that there was an emphasis on developing the staff team, improving moral and valuing the staff. Staff spoken to confirmed that since the appointment of the new manger there had been improvements in the whole environment and feel to the home. The manager consulted them about the way the home operated and one member of staff said that since the new manager had been at the home she herself “had been given more autonomy in developing the menus and the ordering of the food”. It was noted by the inspectors that the manager was approachable and created a positive and inclusive atmosphere. Abbotsford Nursing Home F55 F05 s62280 Abbotsford V236823 D050705 Stage 4.doc Version 1.40 Page 21 The manager must apply to the Commission for Social Care Inspection for registration. The home had a folder containing the policies and procedures. However they were not dated so it was impossible to determine if they had been updated in light of changing legislation and of good practice advice. Once reviewed the file must be made accessible to all staff. It was observed that some documents and posters were still displaying the name of the previous registered providers. The manager informed the inspectors that staff were not currently receiving supervision. During a tour of the building a number of health and safety issues were identified. 1. A numbr of fire doors were found to be wedged open 2. The home’s kitchen including the cooker and deep fat fryer were found to be in need of a thorough deep clean. 3. The control knobes for the hob and oven were not properly fixed and could be pulled away from the cooker. 4. The colour coded chopping boards were found to stored directly on top of each other. 5. Food was being stored directly on the floor. Abbotsford Nursing Home F55 F05 s62280 Abbotsford V236823 D050705 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 x 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 2 x 2 2 x x 2 x STAFFING Standard No Score 27 2 28 x 29 x 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 2 x 2 x x 2 x 2 Abbotsford Nursing Home F55 F05 s62280 Abbotsford V236823 D050705 Stage 4.doc Version 1.40 Page 23 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 1 Regulation 5 Requirement 1. All residents and prospective residenst must be provided with an up to date Service User Guide. 2. An up to date copy of the Service User Guide must be provided to the Commission for Social Care Inspection. (Previous timescale of 1/4/05 had not been met). 1. All residents must have an individual plan of care that sets out in detail the action which needs to be taken by care staff to ensure that all aspects of heatlh, personal and care needs are met. 2. The residents care plan must be reviewd on a monthly basis to reflcet any changes to care needs. 3. 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 for by the resident Abbotsford Nursing Home F55 F05 s62280 Abbotsford V236823 D050705 Stage 4.doc Version 1.40 Page 24 Timescale for action 31/8/05 2. 7 15 30/9/05 whenever possible and/or their representative. (Previous timescale of 1/4/05 had not been met). 3. 7 13 1. The plans of care must include 38/9/05 detailed risk assessments to ensure unnecessary risks to the health or safety of residents are identified and so far as possible eliminated. (Previous timescale of 1/4/05 ahd not been met). 2.The use of bed rails must be accompanied by the use of protective bumpers to ensure that unnecesary risks to the health or safety of reidents are so far as possible eliminated. The provider must ensure that a 31/8/05 record is kept of any nursing care provided to the resident, including a record of his/her conditon and any treatment. The home must ensure that 31/8/05 evidence is provided that care staff maintain the personal and oral hygiene of each resident and wherever possible support the residents own capacity for selfcare. (Previous timescale of 1/4/05 had not been met). Evidence must be provided that residents are consulted about the programme of activities arranged by the home. (Previous timescale of 1/4/05 ahd not been met). The provider must ensure that every resident or any person acting on behalf of a resident is supplied with a written copy of complaints procedure. F55 F05 s62280 Abbotsford V236823 D050705 Stage 4.doc 4. 7 17 Schedule 3 12 5. 8 6. 12 16 31/8/05 7. 16 22 31/8/05 Abbotsford Nursing Home Version 1.40 Page 25 8. 18 13 1. The homes policies and 31/8/05 procedures for responding to suspician or evidence of abuse or neglect must be reviewed and updated to clearly reflect the Departments of Health No Secrets guidence. 2.All staff must receive training in the action to be taken in the event of an allegation of abuse. (Previous timescale of 31/5/05 had not been met). A full audit of the home and in particular all the bedrooms decoration and furnishings is required to ensure that all parts of the home are kept clean and resonabley deocrated/furnished. The sluices must be kept locked to ensure that any unnecessary risk to the health or safety of residents are as far as possible eliminated The bath panel in the bathroom next to room 203 must be replaced All windows must be fitted wth appropriate restrictors to limit the potential for avoidable accidents. The manager must ensure the dependency levels of the residents are regulary reviewed to ensure the staffing levels are sufficient to meet their assessed needs. 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. 2. Evidence must be provided that all PIN numbers have been 9. 19 23 30/9/05 10. 21 13 30/7/05 11. 12. 21 25 13 13 30/7/05 30/7/05 13. 27 18 30/8/05 14. 29 19 31/7/05 Abbotsford Nursing Home F55 F05 s62280 Abbotsford V236823 D050705 Stage 4.doc Version 1.40 Page 26 checked with the NMC. 3. A system must be implemented to check renewal dates of PIN numbers and work permits (Previous timescale of 31/1/05 had not been met). 1.All members of staff must receive induction training within the first 6 weeks of appointment 2. The provider must ensure that all staff employed at the home receive appropriate training. The manager must apply to the Commission for Social Care Inspection for registration. 1. Evidence must be provided that all policies nad procedures have been reviewd and updated in light of changing legislation and of good practice advice. 15. 30 18 30/9/05 16. 17. 31 33 9 12 31/8/05 30/9/05 18. 19. 36 38 18 13 2. Once updated the policies and procedures must be accessible to all staff. Evidence must be provided staff 31/8/05 working at the home home are appropriatley supervised. 1. Fire doors must not be 31/8/05 wedged open 2. The homes kitchen including the cooker must be thoroughly deep cleaned 3. The broken hob and oven knobes on the cooker must be repaired 4. Colour coded chopping boards must not be stored directly on top of each other· 5. Food must not be stored on the floor. Abbotsford Nursing Home F55 F05 s62280 Abbotsford V236823 D050705 Stage 4.doc Version 1.40 Page 27 20. 22 12 1. All wheelchairs must be kept 31/8/05 clean and fit for use by individual residents. 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 12 Good Practice Recommendations 1. The home should maintain a record of all activities 2. It is recommended that the home should employ the services of an activity co-ordinator It is recommended that the home display a menu written in a fomat to suit the capacities of all residents which includes alternative meals. It is recommended that all staff members have an individual training and development plan. It is recommended that all reference to the previous registered provider should be removed from any of the homes documents. 2. 3. 4. 15 30 33 Abbotsford Nursing Home F55 F05 s62280 Abbotsford V236823 D050705 Stage 4.doc Version 1.40 Page 28 Commission for Social Care Inspection 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 F55 F05 s62280 Abbotsford V236823 D050705 Stage 4.doc Version 1.40 Page 29 - 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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