Inspection on 21/09/07 for Abbotsleigh Mews Nursing Home

This inspection was carried out on 21st September 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

Abbotsleigh Mews Nursing Home 25/01/07

Abbotsleigh Mews Nursing Home 28/11/05

Abbotsleigh Mews Nursing Home 08/06/05

Abbotsleigh Mews Nursing Home 23/11/04

Abbotsleigh Mews Nursing Home 12/07/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Abbotsleigh Mews Nursing Home Old Farm Road East Sidcup Kent DA15 8AY Lead Inspector Maria Kinson Unannounced Inspection 21st September 2007 09:25 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 Abbotsleigh Mews Nursing Home DS0000006751.V343969.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. Abbotsleigh Mews Nursing Home DS0000006751.V343969.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbotsleigh Mews Nursing Home Address Old Farm Road East Sidcup Kent DA15 8AY 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) 020 8308 9590 020 8308 9540 lawrenja@bupa.com www.bupa.com BUPA Care Homes (CFHCare) Limited Mrs Tracey Cheeseman Care Home 120 Category(ies) of Dementia (60), Old age, not falling within any registration, with number other category (60) of places Abbotsleigh Mews Nursing Home DS0000006751.V343969.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. One service user on the Macmillan House, can be over the age of 40 years. The Manager of the home must notify the Commission in writing, (without delay) when the 1 service user named in the letter dated the 18/07/2006 moves from the Berens Unit. Macmillan House will provide nursing care to people with Old Age, 30 places. Berens House will provide nursing care to people with Dementia, 30 places. Smythe House will provide Personal Care to people with old age, 30 places. Calvin House will provide personal care to people with Dementia, 30 places 2nd August 2002 Date of last inspection Brief Description of the Service: Abbotsleigh Mews is situated in a residential area of Sidcup, within walking distance of bus routes and a railway station. The home is purpose built and consists of four separate units, each of which is registered to provide care for up to 30 residents. The ground floor units are Calvin House, which provides personal care to residents with dementia and Macmillan House, which provides nursing care. The first floor units are Berens House, which provides nursing care for residents with dementia, and Smythe House, which provides personal care. Administration, catering and laundry facilities are centrally located within the home. All bedrooms in the home are for single occupancy and have ensuite facilities. Residents have access to the homes grounds and there is a separate secure patio/garden area for people living in Calvin House. There is a car park for staff and visitors. The fees charged by the home range from £454.49 - £915 per week. This does not include additional charges such as chiropody, hairdressing and newspapers. This information was supplied to the commission on 30.07.07. Abbotsleigh Mews Nursing Home DS0000006751.V343969.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out by two inspectors and was unannounced. The inspectors spent three to four hours on each unit on 21/09/07. During this period the inspectors spoke with some of the people living in the home, their relatives and staff and observed care practices. Care and medication records were examined. All of the communal areas and a small number of bedrooms were viewed. One inspector returned to Macmillan on 02/10/07 to assess wound care records and to provide feedback for the Registered Manager who was not on duty on the day of the inspection. Written feedback about the service was obtained from seven people that lived in the home, sixteen relatives, two members of staff and six health care professionals. The inspector also spoke with three people on the telephone. What the service does well: People that were unwell were referred to the GP and support and advice was obtained from other health care professionals when required. People said that staff respected their privacy and “treated everyone with respect”. There was a varied programme of activities on most of the units. The manager was recruiting new activity staff and was exploring ways of improving access to activities for some minority groups within the home. The work that was taking place to prepare life history files for the people living on Berens was excellent. Relatives said they were able to visit when they wanted and stay for as long as they liked. Most people said they liked the food provided. Complaints were investigated promptly and written or verbal feedback was provided. CSCI and Social Services were advised about significant events and allegations. The home employed a dedicated training coordinator who was responsible for ensuring that staff attended and had access to relevant training sessions. Staff said the training and support they received to update their knowledge was good. Abbotsleigh Mews Nursing Home DS0000006751.V343969.R01.S.doc Version 5.2 Page 6 The service was assessed regularly to ensure that staff followed company procedures. Feedback about the service was obtained from surveys and during meetings. This information was used to identify good practice and areas for improvement. Good records were kept about people’s personal money and valuables. The grounds and gardens were maintained to a very high standard. Regular checks and inspections were carried out to ensure that equipment was in working order and safe. What has improved since the last inspection? What they could do better: Staff did not maintain adequate records about the receipt of non- prescription medicines such as paracetemol and the homely remedy list did not provide suitable information for staff. Staff on one unit had written peoples room numbers on medication boxes. Although this practice assists staff to locate medication quickly it does present a significant risk if the label is not amended when people move rooms or if the supply is not removed when people leave the home. The amount of medication in the trolley was not always correct when checked against the records and some medication boxes included more medicine than was supplied. The home has demonstrated that it has the Abbotsleigh Mews Nursing Home DS0000006751.V343969.R01.S.doc Version 5.2 Page 7 capacity and skills to address these issues but must also sustain any improvements. A consistent management of medication system is essential There was an unpleasant odour in parts of the lounges on Calvin and Berens. Staff had tried cleaning the carpets more regularly but this had not resolved the issue. Plans were in place to replace the carpet with laminate flooring. Some large pieces of equipment were stored in the quiet lounge on Macmillan. This looked unsightly. There had been some difficulties maintaining adequate domestic and care staffing levels. Some action was taken to address this issue but a number of residents said that staff were “overstretched” and that they had to wait for help to use the toilet or have a bath. Recruitment checks were carried out but staff must obtain more information from referees and check that nursing staff are still registered to practice. This is a further area that requires consistent management. Staff were moving people in wheelchairs without footplates. This practice could result in injuries. 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. Abbotsleigh Mews Nursing Home DS0000006751.V343969.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 Abbotsleigh Mews Nursing Home DS0000006751.V343969.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 does not apply to this home. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff obtained information about peoples health and social care needs before they moved into the home. EVIDENCE: The information that was obtained about peoples needs before they moved into the home had improved. New documentation had been introduced which prompted staff to obtain specific information about people’s health and social care needs and the level of support they required. The assessments viewed for some of the people that had moved into the home in recent months were mostly satisfactory. Staff received training and support to complete the new records and systems were in place to check that the documentation was properly completed. Abbotsleigh Mews Nursing Home DS0000006751.V343969.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 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans provided guidance for staff about the action they should take to meet people’s health and social needs. Work had been undertaken to improve the management of medication in the home but a number of new concerns were identified. EVIDENCE: Four sets of care records were assessed. As indicated previously new documentation had recently been introduced. This involved a significant amount of work for staff that had to review all of the existing records and transfer information to the new paperwork. Staff received support from the training officer and a link person. Although some parts of the records in some files were incomplete the content of information recorded was good overall. Some care plans provided detailed information about people’s preferences such as female staff to assist with personal care and a request to have their feet soaked regularly. There was some evidence that relatives and residents were Abbotsleigh Mews Nursing Home DS0000006751.V343969.R01.S.doc Version 5.2 Page 11 involved in the care planning process and were advised about significant events. Care plans were reviewed regularly. One care plan included information about the management of pressure sores and wounds. The plan provided information about the location, size and appearance of the sores and the type and frequency of dressing changes. Photographs and a wound evaluation record were maintained to show how the wounds were progressing. Specialist advice was obtained from a tissue viability nurse. Staff identified potential or actual hazards and recorded strategies to maintain peoples safety. Assessments were seen for people that were at risk of developing pressure sores, becoming malnourished, falling and who had difficulty moving. Records indicated that people living in the home had access to community health care services and 71 of people were satisfied with the medical support they received. The commission obtained written feedback about the service from six health care professionals that were in regular contact with the home. The feedback provided was mostly positive with most professionals stating that the service was “good” and that staff provided “excellent” care. Respondents said that staff were ‘always’ or ‘usually’ able to meet peoples health care needs and ‘always’ respected peoples privacy and dignity. Three people expressed concerns about staffing levels stating that staff did not have “adequate time to spend with residents” and that staff that provided assistance during consultations or assessments were “frequently called away”. See standard 27. Since the last inspection the home had changed to a new pharmacy supplier and had developed a number of audits to address some of the concerns that were identified during the previous inspection. Most of the issues identified at the last inspection had been addressed but a number of new concerns were identified. Medication was assessed on two of the four units (Calvin and Macmillan). Records of receipt and disposal of medication were good and all medicines were in stock. Administration records were mostly satisfactory but some staff did not use their full initials when signing the record and some staff did not provide clear information about the reason why medication was not given. On Calvin staff had written peoples room numbers on medication that was not supplied in blister packs. There is a risk that medication errors could occur if a person then moved rooms. Some discrepancies were identified when the amount of medication administered was deducted from the amount received in the home. There were more tablets than were received in the home, in some of the boxes on Calvin. This may be due to staff transferring medication from one container to another. This issue only relates to medication that was supplied in boxes. Storage facilities were good overall but the medication refrigerator on Calvin was running above the recommended temperature. Abbotsleigh Mews Nursing Home DS0000006751.V343969.R01.S.doc Version 5.2 Page 12 Staff had reported this issue to maintenance staff but there was no evidence that any action had been taken to rectify the problem. The homely remedies list on Calvin was agreed and signed by the GP. The list did not include adequate information for staff such as the recommended dose. One medicine was administered by staff but was not included on the agreed homely remedies list. It was not possible to audit some of the homely remedies such as paracetemol, as there was no record of the amount received in the home. See requirement 1 to 4. All bedrooms were single occupancy. Bathroom doors had locks fitted and care plans addressed the need for privacy when bathing people. Abbotsleigh Mews Nursing Home DS0000006751.V343969.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 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People had access to a varied and interesting programme of activities and were usually satisfied with the choice and quality of food provided in the home. EVIDENCE: All of the units had a dedicated activities person but there were fewer activities taking place on Macmillan and Smythe due to staff vacancies. Activity staff organised a varied programme of individual and group activities and social events. The programme included sessions that people liked such as quizzes and dances but was amended if necessary to meet people’s needs. On Beren’s the activity coordinator was working with the people living in the home and their relatives to prepare a personal history file for each person. The file included information about the person’s life history, old photographs and records of personal achievements. Some people enjoyed looking at their file with relatives or staff. Abbotsleigh Mews Nursing Home DS0000006751.V343969.R01.S.doc Version 5.2 Page 14 The activity coordinator and residents on Calvin had developed a sensory garden at the front of the unit. The garden won a prize in the ‘Bexley in Bloom’ competition. One of the people living on the unit attended an award ceremony to accept the prize on behalf of the unit. People said that they were able to visit the hairdressing salon or attend religious services if they wanted. One person on Smythe said they were aware of the activity programme but did not attend the sessions through choice. This person said they liked to keep themselves busy by assisting staff with administration work and preparing the menus for the unit. Staff encouraged this person to actively contribute to the running of the unit. There was little evidence of activities in the records on Macmillan. The manager said that the vacant post on this unit would be filled. Staff had identified that there was a lack of activities for men and that there were few opportunities for people from different units and different BUPA homes to pursue common interests together. The manager said that these issues were being discussed with residents, relatives and activity staff. Relatives said they could visit the home when they wanted and were made to feel welcome. Written comments about the service were obtained from sixteen relatives. Feedback was mostly positive but a number of relatives expressed concerns about staffing levels. See standard 27. 87 of relatives said that staff ‘always’ or ‘usually’ informed them about important issues and the care records seen on some of the units supported this. There were opportunities for relatives to attend unit meetings and to give feedback about the service if their family member was not able to do this. A new newsletter was about to be launched. The newsletter will provide information about activities and events in the home and provide opportunities for people to comment or make suggestions about the service. Lunch was observed on Macmillan and Calvin. Most people had their meal in the dining area but a small number ate in their room through choice. Staff used their knowledge of people’s likes and dislikes and followed the record that showed what dish people had chosen to eat. People were seen eating a number of different foods such as steamed or fried fish, salads and sandwiches. Some people had special cutlery or aids to assist them to eat independently and assistance was provided if necessary. Most people said that they ‘usually’ liked the food provided but a few people said that the standard of food was sometimes variable and there was often too much to eat. Staff on Macmillan added cream, milk or butter to some peoples diet. This provided extra nutrients and calories for people with a poor appetite. Staff confirmed that they received the items listed on the ‘Night Bite Menu’. Abbotsleigh Mews Nursing Home DS0000006751.V343969.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 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had procedures in place for staff to follow when investigating complaints or concerns. All grades of staff received abuse training and were aware of adult protection issues. EVIDENCE: The complaints procedure was displayed in the home and was included in the Service User Guide. All of the relatives that provided written feedback about the service were aware of the homes complaints procedure. The home had received nine complaints about care, cleanliness, food, staffing and environmental issues since the last inspection. Complaints were logged in a file and were investigated promptly. The manager and operations manager had met some complainants to discuss their investigation and findings or had provided a written response. Two relatives indicated that they were not were not satisfied with how their concerns were addressed in the past and one person said that there were some improvements for a period but this was not sustained. The manager should consider implementing a questionnaire or system to identify people’s satisfaction with the way their complaint was handled. This may identify areas for improvement. See recommendation 1. Abbotsleigh Mews Nursing Home DS0000006751.V343969.R01.S.doc Version 5.2 Page 16 Four issues of concern were investigated under the local authority safeguarding procedures since the last inspection. The manager investigated all of the issues with support from social services. Two of the allegations were not substantiated and action was taken to monitor the behaviour of one resident. Disciplinary action was taken against one member of staff. Care staff had a good understanding of safeguarding procedures and were aware that allegations or concerns should be reported to senior staff. Staff received protection of vulnerable adults training during induction and regular training updates were provided for all grades of staff. Abbotsleigh Mews Nursing Home DS0000006751.V343969.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This home provides a comfortable environment for the people using the service and their visitors. Plans were in place to refurbish parts of the home and to resolve some ongoing problems with odour. EVIDENCE: The home was clean, tidy and well maintained. Efforts had been made to make the communal areas homely and to personalise people’s bedrooms. Many of the rooms seen included personal photographs, pictures and small items of furniture from the person’s family home. Some of the décor and furniture were showing signs of wear and tear but most areas were furnished to a satisfactory standard. A programme of refurbishment will take place in 2008 and a budget had been agreed for this Abbotsleigh Mews Nursing Home DS0000006751.V343969.R01.S.doc Version 5.2 Page 18 work. The manager was not certain what the programme would include as each unit had to be individually assessed and residents, relatives and staff would be asked to contribute ideas. The lighting in Beren’s unit was not very bright and the television screen was rather small. The manager agreed to ask the surveyor to consider the lighting on Beren’s when assessing work for the planned refurbishment programme. A new television and DVD player had been ordered for the unit. A bell was fitted in the lounge on Calvin to alert staff to incoming telephone calls. The noise made by the bell was rather loud and seemed to startle some people. The manager said that she was considering purchasing cordless telephones that the person in charge could carry with them. This should resolve this issue. On Smythe some of the curtains and furniture were old and worn. There were no curtains at some of the windows in the lounge and the cushions on some chairs provided little support. Although the refurbishment programme will address these issues some interim action needs to be taken to provide suitable curtains in the lounge. There were signs on the bathroom and toilet doors to help people with dementia to locate these facilities. Staff should consider simplifying some of the signs on Beren’s and consider applying signs to en suite doors. See recommendation 2. There was a lack of suitable storage space in the home for moving and handling equipment. On Macmillan one person was asleep in their wheelchair in the small lounge. The person was surrounded by hoists and wheelchairs. The manager should consider how this issue could be resolved. See recommendation 3. Although the home was clean and tidy on the day of the inspection it was evident that there had been some difficulties maintaining the cleanliness of the home in recent weeks. One relative said she had to call staff to vacuum her family members room because the carpet was “filthy” and several residents said they were not satisfied with the cleaning arrangements. Some residents and one relative said they were doing their own cleaning. The manager said that four domestic staff resigned at the same time, three of which did not work their notice period. Although the manager had recruited some new domestic staff they were not able to commence work in the home until pre-employment checks were carried out. As an interim measure the manager had arranged for some of the laundry, maintenance, care and management staff members to assist with cleaning and had arranged for a team of staff from another BUPA home to deep clean some of the units. Abbotsleigh Mews Nursing Home DS0000006751.V343969.R01.S.doc Version 5.2 Page 19 The manager had also experienced difficulties obtaining temporary staff, as some agencies did not complete criminal record checks. There was an unpleasant odour in parts of the communal lounges on Beren’s and Calvin. One relative also raised this issue. The manager said that extra carpet cleaning had been implemented but this had not resolved the issue. A decision had been made to fit laminate flooring on these units. See requirement 5. The grounds and gardens at the front of the property were maintained to a very high standard. The rose beds and lawns were immaculate and there were plenty of areas where residents and relatives could sit and relax. Abbotsleigh Mews Nursing Home DS0000006751.V343969.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Staffing levels did not always meet people’s needs. Vetting procedures did not always provide adequate protection for people using the service. Staff received support to update their knowledge and skills and to gain recognised qualifications. EVIDENCE: A number of concerns were raised about staffing levels in comment cards and during conversations with residents, staff and relatives. On the day of the inspection the minimum staffing levels, as listed in the home were not met on some of the units. Staff told the inspector that they had arrived on duty an hour early because they knew they were going to be short of staff and would not be able to get their work done. Some staff said they felt stressed because they could not complete all of the tasks expected and that that there were periods when there was one nurse instead of two on duty. Senior staff said they were not able to support junior staff or take supernumerary hours to complete staff supervision and management duties. Some of the people living in the home said that staff were “overstretched” and were frequently “moved from unit to unit” because other units were short staffed. Abbotsleigh Mews Nursing Home DS0000006751.V343969.R01.S.doc Version 5.2 Page 21 Some relatives said that staff did not have “adequate time to talk to people”, and there were “not enough staff on duty to attend to the requirements of patients”. Berens and Smythe did not have adequate staff on the day of the inspection but some staff were moved from other units to help out. The staffing roster for the period 21/10/07 to 04/10/07 was examined. The roster supported the concerns raised about staffing levels and confirmed that there were periods when there was only one trained nurse on duty on one of the nursing units. Some of the duty rosters were difficult to interpret in parts because it was not recorded if bank staff were trained nurses or care staff and the shifts worked by a couple of staff were unclear. For instance the roster for two staff said “in”. On one occasion a staff nurse had worked an early, a late and a night shift in one day. This could compromise people’s safety. See requirement 6. The manager acknowledged that the home had experienced difficulties with staffing in recent weeks but said that efforts were being made to increase the number of bank staff and to recruit new staff. The manger advised the inspector that there were adequate trained staff in post to cover staff sickness and vacancies on Macmillan. The deputy manager was also working on this unit for a period. People living in the home praised staff for their caring and compassionate approach. Relatives said that most staff were ”marvellous” and “treated everyone with respect”. Some concerns were raised about the communication skills of some of the junior staff that worked on Macmillan. The manager had arranged for the deputy manager to work on this unit for a period to monitor this issue and support staff. 51 of care staff had attained a vocational qualification in care at level two or three. Fourteen care staff were currently registered to complete this programme of training. Three staff recruitment files were examined. Pre- employment checks were carried out for most staff but the file for a staff member that was employed prior to the introduction of the Care Standards Act did not include any written references or evidence of registration with the Nursing and Midwifery Council. Some of the references for the other staff members were not verified to confirm that they were genuine. See requirement 7. The training coordinator was responsible for assessing staff training needs and ensuring that staff had access to relevant training sessions. New staff attended a two-day induction-training course and completed an induction workbook that covered all of the common induction standards. Abbotsleigh Mews Nursing Home DS0000006751.V343969.R01.S.doc Version 5.2 Page 22 Some members of staff had attended care planning, fire safety, moving and handling, nutrition, bedrail and mental capacity act training sessions since the last inspection. Staff were satisfied with the training arrangements and said the sessions helped them to meet people’s needs. Abbotsleigh Mews Nursing Home DS0000006751.V343969.R01.S.doc Version 5.2 Page 23 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, and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was well organised and there were good systems in place to monitor health and safety issues and safeguard residents money. EVIDENCE: Abbotsleigh Mews Nursing Home DS0000006751.V343969.R01.S.doc Version 5.2 Page 24 A new manager was appointed in June 2007. The manager had worked in various hospital and community settings and previously managed another BUPA care home. The manager has a nursing qualification and is currently undertaking the registered managers award. The manager was assessed by the commission to have suitable skills and experience to manage a care home for older people. Staff did not feel able to comment about the approach of the new manager, as she had not been in post for very long. Staff said the deputy manager visited the units regularly and was very supportive. Regular audits were taking place and action plans were developed to address problem areas. The company send out an annual satisfaction survey. The results from surveys were collated and used to improve the service. The administrator was responsible for maintaining adequate records and keeping peoples personal money and valuables safe. Some people were able to look after their own money and in these cases signed to confirm that they had received money from staff. Personal money was held in a joint account and interest was calculated and paid on a pro rata basis. The money records for two people were checked and were found to be correct. A recent financial audit indicated that staff followed company procedure and maintained good records. The fire alarm system and emergency lighting were regularly serviced and the fire alarm was tested once a week. Two monthly fire drills were held on each of the units. The drills were carried at various times of the day so that the maintenance person could assess the response of both day and night staff. Records showed that regular checks were carried out on items such as wheelchairs, hot water temperatures and the nurse call system. Some of the recent accident reports were examined on Smythe and Calvin. Those seen were well written and provided factual information about the event. Staff had access to moving and handling equipment and an individual assessment stating how each person should be moved was completed. Staff received moving and handling training when commencing work in the home and regular updates thereafter. Some of the wheelchairs that were in use on Berens did not have footplates fitted. This issue must be addressed to reduce the risk of people sustaining injuries. See requirement 8. A risk assessment was completed for people that were using bedrails and training about the use of this equipment was provided for staff. The home used four bar bedrails and padded covers to help maintain peoples safety. The maintenance technician checked bedrails on a monthly basis to ensure they were fitted securely and correctly positioned. Abbotsleigh Mews Nursing Home DS0000006751.V343969.R01.S.doc Version 5.2 Page 25 Abbotsleigh Mews Nursing Home DS0000006751.V343969.R01.S.doc Version 5.2 Page 26 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 1 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 3 X X 2 X X X 3 STAFFING Standard No Score 27 1 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 X X 3 Abbotsleigh Mews Nursing Home DS0000006751.V343969.R01.S.doc Version 5.2 Page 27 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 OP9 Regulation 13 Requirement The Registered Person must ensure that internal audits of medication are effective in identifying and addressing the issues found during this inspection. The Registered Person must ensure that accurate records are kept for all aspects of medication handling, administration and storage. The previous timescale of 09/05/07 was not met. The Registered Person must ensure that staff do not mark medicines with people’s room numbers or transfer medicines from their original container. The Registered Person must ensure that adequate records are maintained about homely remedies. The homely remedies list must be reviewed and updated. The Registered Person must take action to control odour and keep all parts of the home fresh. The previous timescale of 09/05/07 was not met. DS0000006751.V343969.R01.S.doc Timescale for action 30/11/07 2. OP9 13 30/11/07 3. OP9 13 30/11/07 4. OP9 13 28/12/07 5. OP26 16 28/12/07 Abbotsleigh Mews Nursing Home Version 5.2 Page 28 6. OP27 18 7. OP29 19 8. OP38 13 The Registered Person must ensure that there are adequate staff on duty at all times to meet peoples needs. The Registered Person must ensure that adequate preemployments checks are carried out before staff commence work in the home. The Registered Person must ensure that staff are instructed about the correct use of wheelchairs. 30/11/07 30/11/07 28/12/07 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. Refer to Standard OP16 Good Practice Recommendations The Registered Person should introduce a system for monitoring peoples satisfaction with the way and manner in which their complaint was handled. This information should be used if necessary to improve the service. The Registered Person should review the provision of signage for people with dementia. The Registered Person should identify alternative storage space for large equipment such as hoists and wheelchairs. 2. 3. OP19 OP22 Abbotsleigh Mews Nursing Home DS0000006751.V343969.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection SE London Area Office River House 1 Maidstone Road Sidcup Kent DA14 5RH 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. 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