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Inspection on 28/11/05 for Abbotsleigh Mews Nursing Home

Also see our care home review for Abbotsleigh Mews Nursing Home for more information

This inspection was carried out on 28th November 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

Residents received good care in this home and residents and relatives praised the staff for their hard work, kindness and commitment. The home was well managed and staff were provided with the training they needed. Residents had care plans and they received good health care. Medication was well managed. Activities and entertainment were provided and relatives were made welcome by staff when they visited. Complaints had been very well dealt with and there had been no concerns about the safety of residents in the home since the last inspection. The home was clean, well decorated, comfortable and well maintained.

What has improved since the last inspection?

Residents and relatives were more aware of their care plans and had been more involved in drawing them up. There were care plans for residents who had or were at risk of developing pressure sores and medication was better managed. Parts of Calvin House had been redecorated so as to help residents find their way around easily.

What the care home could do better:

Though medicines had been generally safely dealt with, some additional precautions were needed. The cause and circumstances of accidents must be looked into, so that they can be better prevented in the future. Residents liked the food but a choice of meal should be offered. Care planning should be extended to include additional areas of residents` lives and staffing levels in Calvin House should be increased, in response to residents` changing needs.

CARE HOMES FOR OLDER PEOPLE Abbotsleigh Mews Nursing Home Old Farm Rd East Sidcup Kent DA15 8AY Lead Inspector Elizabeth Brunton Unannounced Inspection 28th November 2005 10:00 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.V250491.R01.S.doc Version 5.0 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.V250491.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Abbotsleigh Mews Nursing Home Address Old Farm Rd 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 BUPA Care Homes Limited Ms Janet Lawrence Care Home 120 Category(ies) of Dementia (30), Old age, not falling within any registration, with number other category (90) of places Abbotsleigh Mews Nursing Home DS0000006751.V250491.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 48 nursing beds for frail elderly aged 60 years and 12 beds for people aged 50-59 years 30 residential beds for the frail elderly aged 65 30 residential beds for mental disorder other than mental handicap Date of last inspection 8th June 2005 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, 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 en-suite facilities. Residents have access to the home’s 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. Abbotsleigh Mews Nursing Home DS0000006751.V250491.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and two inspectors were in the home from 10am until 5.30pm. Most time was spent in Calvin and Macmillan Houses and a number of residents, visiting relatives, the manager and other staff on duty were spoken to. Communal rooms, the garden and some residents’ bedrooms were seen. Records were looked at, together with some service users’ individual case files. What the service does well: What has improved since the last inspection? What they could do better: Though medicines had been generally safely dealt with, some additional precautions were needed. The cause and circumstances of accidents must be looked into, so that they can be better prevented in the future. Residents liked the food but a choice of meal should be offered. Care planning should be extended to include additional areas of residents’ lives and staffing levels in Calvin House should be increased, in response to residents’ changing needs. Abbotsleigh Mews Nursing Home DS0000006751.V250491.R01.S.doc Version 5.0 Page 6 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. Abbotsleigh Mews Nursing Home DS0000006751.V250491.R01.S.doc Version 5.0 Page 7 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.V250491.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3&4 Residents and relatives said that good care was provided in the home. Assessments of need were seen for some residents. Some residents in the nursing units were suffering from dementia, which was not in line with the home’s registration. EVIDENCE: Pre-admission assessments of residents’ needs and abilities were seen on files in Calvin House and relatives confirmed that they had contributed to these. Residents and relatives spoken to said the home met residents’ needs. One relative said that she was ‘highly delighted’ with the care given in Calvin House. There were a number of residents with dementia on the nursing units and training was currently being provided for all staff in dementia care. One resident had been reviewed and was waiting to move to a dementia nursing home. The manager said there were plans to apply for a change in the registration of one of the nursing units, to enable the home to provide dementia nursing care. If this is not planned for the near future, an application should be made for variation in registration, for those residents in Abbotsleigh Mews Nursing Home DS0000006751.V250491.R01.S.doc Version 5.0 Page 9 the nursing units who have been diagnosed as suffering from dementia. (see recommendation 1) Abbotsleigh Mews Nursing Home DS0000006751.V250491.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 & 11 Care plans were in place but some additional care planning was needed. Healthcare needs had been well met. Medication was safely stored and well managed but some additional written information was needed. Residents’ privacy and dignity had been respected and upheld, though two recommendations are made. Good care was being given to a resident who was nearing the end of her life. EVIDENCE: Care plans for were seen on all files inspected and individual care plans related to resident’s identified needs. In Calvin House, care plans for meeting one resident’s communication, activity and psychological well-being needs were seen. However, care plans for meeting these needs were not in place for three other residents whose files were inspected and this was also the case in Macmillan House. One resident with challenging behaviour had a care plan in place for managing this. Residents in Macmillan House and most relatives spoken to had been involved to some extent in the care planning process. Residents and relatives spoken to were satisfied with the care provided. Staff spoken to in both units visited showed a good understanding of residents’ needs and of the plans for meeting these. (see recommendation 2) Abbotsleigh Mews Nursing Home DS0000006751.V250491.R01.S.doc Version 5.0 Page 11 Risk assessments had been completed for the development of pressure sores, moving and handling, falls and nutrition. The action needed to reduce these risks had been incorporated into care plans. Residents said their health care needs were well met and this was confirmed by relatives spoken to. Information about residents’ health care needs was seen on file and details of healthcare appointments had been recorded. Records showed that residents were registered with a GP and had access to other routine health care, such as dental, optical, chiropody and hospital treatment, when required. In Macmillan House, the sister said staff had access to a CPN for advice on the care of residents with dementia. One very unwell resident in Calvin House was receiving care for a pressure sore from the district nurses. A care plan was in place and a pressure-relieving mattress had been provided. Equipment such as pressure relief mattresses and cushions were seen on beds and chairs in Macmillan House, where staff confirmed that advice on the care of pressure sores was sought from the tissue viability nurse at the PCT. Although care plans were prepared in relation to wound care in Macmillan House, records did not clearly show the condition of the wound, the dressings used and dressing renewal dates, in an ‘easy to follow’ format. (see recommendation 3) Medication was inspected in Calvin and Macmillan Houses and was properly stored in both houses. Records showed that the clinical room in Calvin House had been maintained at a safe temperature but the temperature of the medication fridge had regularly been too high. The nomad system was used, with some medicines supplied in bottles. Medication and administration records were inspected for a number of residents in each house and no anomalies found. Controlled drugs were also properly stored and administered and eye drops had been marked with the date of opening. A number of homely remedies were available but the GP’s agreement to residents taking these was unclear in Calvin House. The supplying pharmacist was currently taking away medicines for disposal and accurate records of this were seen in Macmillan House. A risk assessment had been completed for one resident who self-administered some of their medicines. However, it did not include issues such as whether the resident was able to open the container, administer the medication correctly and ensure safe storage of the medicines. (see requirements 1, 2 & 3) Residents were seen to be treated with respect by staff and their dignity and privacy maintained. Visiting relatives confirmed this. Staff were heard to speak to residents in a friendly and polite manner. In Calvin House, there was evidence on file that residents or their relatives had been asked whether they would like a key to their bedroom doors. Some relatives had asked for residents’ bedroom doors to be locked when the rooms were unoccupied. This had been done for all but one of the rooms checked. The inspector spoke to one resident who was anxious about people going into her room and said that Abbotsleigh Mews Nursing Home DS0000006751.V250491.R01.S.doc Version 5.0 Page 12 she wanted a door key. Her door was not locked, although this had been requested by her relative. However, the manager said that this resident was now to be provided with her own bedroom door key. Bedroom windows in Calvin House did not have net curtains and some had windows and doors overlooking the garden and car park. The possibility of providing net curtains should be discussed with these residents and their relatives, in order to safeguard the residents’ dignity and privacy. (see recommendations 4 & 5) The home was piloting a new and comprehensive care planning approach on behalf of the PCT for residents who were nearing the end of their lives. This was in place for one resident in Calvin House. She was being well cared for by staff, with the support of the GP and district nursing service. Relatives were involved and had been consulted about the resident’s spiritual needs. Pain relieving drugs were already in stock for if and when they needed to be prescribed. Abbotsleigh Mews Nursing Home DS0000006751.V250491.R01.S.doc Version 5.0 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 & 15 Activities were provided for residents, though individual care plans would help to ensure that these meet individual needs. Visitors were made welcome in the home and were kept informed. Varied and nutritious meals were served and residents liked the food. Residents in Calvin House should have more choice of meal. EVIDENCE: Activities organisers were employed and those spoken to were creative and enthusiastic about their work. The programme of activities and entertainment for the week was displayed in each house, though this was said to be varied, according to residents’ needs at the time. An activities organiser worked with residents in Calvin House during most of the day of inspection, making Christmas cards and spending 1:1 time with residents. Residents in Macmillan House said that activities such as skittles, scrabble, quizzes, bingo and sing-alongs were provided and that they could choose whether or not to attend. As previously mentioned, care plans relating to social interaction and activities were not seen on most residents’ files and activities organisers spoken to were not aware of them. Records had been maintained of which activities residents had attended and those seen in Macmillan House showed that many residents took part in activities. A local vicar was now visiting the home each week and Abbotsleigh Mews Nursing Home DS0000006751.V250491.R01.S.doc Version 5.0 Page 14 residents were said to enjoy attending the service. It was said that staffing levels inevitably limited opportunities for residents in Calvin House to go out. Also, that the budget for residents’ activities was limited and had to be supplemented from money raised from raffles and other such activities. However, the manager said that sufficient funds were available for activities. (see recommendation 6) Residents said that their families and friends could visit at any time. This was confirmed by visiting relatives, who said that they were made welcome by staff and were kept informed about their resident. Lunch was served in a calm and organised manner in both Calvin and Macmillan Houses. The meal was well presented and looked and smelled appetising. Residents spoken to said they enjoyed their meal and were pleased with the food provided in the home. A relative who visited regularly said the food was ‘always very good’. There was a choice of main course and pudding but on Calvin Unit, staff said they made the choice on behalf of residents but from a knowledge of residents’ likes and dislikes. If a choice of plated meal could be offered to residents at the table, this would promote their autonomy. One resident ate very little of her meal and told the inspector she would prefer a salad. However, her almost full plate was eventually removed by staff, who did not ask the resident whether she would prefer an alternative meal. Staff did say that this resident was often provided with an alternative, salad meal. Staff were attentive to residents during the meal and offered assistance with feeding, when needed. Some residents in Macmillan House might have found it easier to manage their meal with plate guards in place. (see recommendations 7 & 8) The main kitchen was well organised. The four weekly menus were renewed twice a year and showed that varied and nutritious meals were served. The chef said that if a resident did not like any of the main meal choices, an alternative such as omelette, salad or jacket potato could be provided on request and this was written into the menus displayed in the units. Abbotsleigh Mews Nursing Home DS0000006751.V250491.R01.S.doc Version 5.0 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 The few complaints made had been responded to well and service users appeared to be protected from harm and abuse. EVIDENCE: The manager said there had been three complaints made about the home since the last inspection. Records showed and complainants confirmed that complaints had been thoroughly dealt with, often through face-to-face meetings between the complainant and manager, with senior management involved, where appropriate. A number of letters of appreciation of the care given in the home had been received since the last inspection. No adult protection concerns had been recorded since the last inspection. Care was being taken to prevent residents from leaving Calvin House without staff knowledge, following a past incident. Relatives spoken to said they were confident that residents were safe in the home. Staff showed an awareness of adult protection issues and said they had received training. Abbotsleigh Mews Nursing Home DS0000006751.V250491.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24, 25 & 26 The home was clean, sufficiently spacious, well decorated and maintained. EVIDENCE: As at the previous inspection, the home was bright and well decorated, clean and tidy and there were no unpleasant odours. The garden was very well maintained and there was a separate, secure garden for the use of residents of Calvin House. The lounge/diners in both Calvin and Macmillan Houses were well laid out, with residents seated in different areas, so they could watch TV, listen to music or look out at the garden. Some of the doors and corridors in Calvin House had been redecorated, so as to provide additional assistance to residents with orientation. Small, display boxes had also been fixed to the wall outside each bedroom door. These contained photographs and small ornaments and possession and were a thoughtful and discrete way of assisting residents with identifying their rooms. Bedrooms seen were personalised, well decorated and furnished and residents said they were satisfied with the layout and that their rooms were kept clean. Residents in Calvin House were delighted with their recently acquired kitten. Abbotsleigh Mews Nursing Home DS0000006751.V250491.R01.S.doc Version 5.0 Page 17 Bathrooms and toilets were clean and tidy with hand washing facilities provided. In Macmillan House, the shower room (room 30) ceiling was badly stained and some tiles had come away from the wall by the shower cubicle. Hot water temperatures checked were within safe limits and residents agreed that the home was maintained at a comfortable temperature. Rooms were bright and residents had access to central and over-bed lights in their rooms. (see requirement 4) Grab rails were fitted where needed and there was an adequate number and range of hoists and assisted baths. The home was purpose built, so corridors, doorways and bedrooms were suited to wheelchair use. A number of residents in Macmillan House had motorised scooters to use both in and outside the home. Some wheelchairs and scooters were in need of cleaning and this was pointed out to the sister in charge. (see recommendation 9) Attention had been given to hygiene and infection control. Hand washing facilities were provided where waste was handled, staff had access to adequate supplies of protective clothing and infection control training was provided. The laundry was not inspected but residents had adequate supplies of personal clothing in those bedrooms inspected and linen cupboards were quite well stocked. Tubes of cream were seen in some toilets and bathroom, which staff said were used to wash residents. These creams must not be shared and staff must ensure that residents are provided with their own, labelled tubes of cream. (see requirement 5) A full time maintenance officer was employed, who was hard working and efficient and who undertook regular checks of equipment and the repair of essential items. Abbotsleigh Mews Nursing Home DS0000006751.V250491.R01.S.doc Version 5.0 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 & 30 A competent and committed staff team provided good care to residents. A review of staffing levels in Calvin House and of management time allocated to each unit is recommended. There was a good standard of in-house training and access to NVQ training. EVIDENCE: Residents and relatives spoke positively about the staff and said that they were kind and thoughtful. One relative commented that the staff were excellent. The manager said that that home was fully staffed and that staff turnover had been low. Staff confirmed that Calvin House was fully staffed but that two staff were off sick. Bank staff or staff from other units covered these shifts but agency staff were not used. The manager must ensure that moving staff from other units does not leave any units short staffed. The manager said that five staff were on duty morning and afternoon in Calvin House. However, staff in that unit said that there were sometimes only four staff on duty but that five staff were needed, as two residents required almost 1:1 staffing, due to their challenging behaviour. Recent records indicated that there had been only four staff on duty during half of the shifts. However, the manager said that these records did not show where staff had been brought over from other units and that this was recorded elsewhere. Macmillan House appeared to be adequately staffed. Three residents on that unit said they often had to wait a long time to get up in the morning but gave no other indication of staff shortage. (see recommendation 10) Abbotsleigh Mews Nursing Home DS0000006751.V250491.R01.S.doc Version 5.0 Page 19 Each house was managed by a senior sister/care manager, plus deputy. There were said to be 12/14 hours of management time for each unit manager and deputy. However, some staff did not consider this to be sufficient time to complete all the necessary management tasks, including regular staff supervision and it should be reviewed. Staff recruitment records were seen to be thorough at the last inspection and were not looked at on this occasion. (see recommendation 11) The home had a full time training officer. One of the night sisters had also recently been given some supernumerary hours, to enable her to undertake training with night staff. The training officer kept a record of staff training and ensured that staff received update training when due. This was confirmed by unit managers and staff. Staff were paid to attend training and said that they received adequate support and training to fulfil their roles. Since the last inspection, staff had had access to training such as infection control, moving and handling, health and safety, challenging behaviour, risk assessment and adult protection. More than half of the care staff had achieved or were currently studying for the NVQ 2/3 qualification. Abbotsleigh Mews Nursing Home DS0000006751.V250491.R01.S.doc Version 5.0 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38 The home was well managed. Staff received formal supervision but this needed to be more frequent. Residents’ and relatives’ views of the service were regularly sought. The health and safety of residents and staff had been safeguarded, though hoists needed to be checked more regularly by the contractor and all accidents followed up on. EVIDENCE: Abbotsleigh Mews Nursing Home DS0000006751.V250491.R01.S.doc Version 5.0 Page 21 The home was well managed by a competent and experienced manager, who was committed to meeting the needs of residents and to developing the service. The manager had been in post since October 2004 and had recently gained the registered manager’s award. The manager was well supported by an able training officer, administrators and unit managers and deputies. Staff, service users and relatives spoke positively about the management of the home. BUPA was said to undertake regular resident/relatives surveys. Regular visits were made to the home by the provider and relatives’ meetings were held. An internal system for the monthly monitoring of residents’ care had recently been introduced and this included seeking and recording the views of both residents and relatives. It was not possible to carry out a thorough inspection of the administration of residents’ finances on this occasion, as the member of staff responsible for this area of work was not on duty. However, all residents were said to have a building society account and to receive monthly statements of their finances. The financial records for a number of residents were inspected and appeared to be in order. A few residents were said to manage their own finances. In Calvin House, staff supervision was said take place six monthly, ‘on the job’. Supervision should take place two monthly and should cover the issues listed under this standard. Staff working in Macmillan House said they benefited from supervision sessions, which helped them to focus on their work and to address training needs. (see recommendation 12) Records for the servicing of the home’s gas/electrical installations and equipment and fire safety equipment were checked at the last inspection. The fire log maintained in Macmillan House showed that fire alarms, fire doors, emergency routes and lighting had been regularly checked. Records for fire drills held in each unit during either August or November 2005 were seen. The maintenance officer said that hoists were checked and serviced annually by the contractor and that he also checked them monthly. The manager confirmed that the maintenance officer was trained and certificated to carry out these checks, in line with LOLLER requirements. No risks to residents’ safety were seen in those parts of the building inspected. Call bells tested were in working order and were responded to quickly by staff in both Calvin and Macmillan Houses. However, some residents in Macmillan House indicated that this did not always happen, especially at night. In bedroom 5 in Macmillan House, the call bell unit was not properly fitted to the wall and this was bought to the attention of the sister. (see requirement 6 and recommendation 13) Abbotsleigh Mews Nursing Home DS0000006751.V250491.R01.S.doc Version 5.0 Page 22 The kitchen was very clean, hygienic and well managed. It had been awarded the silver award for clean food by the environmental health department. Temperatures of foods, fridges, freezers and cleaning schedules were well recorded. In Macmillan House, fourteen accidents had been recorded since the last inspection. One of these had been reported by a relative and had been appropriately investigated. The manager said that an unexplained injury sustained by a resident, while being hoisted, had resulted in a major investigation. The manager agreed to provide the CSCI with details of this. Abbotsleigh Mews Nursing Home DS0000006751.V250491.R01.S.doc Version 5.0 Page 23 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 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 2 3 X 3 3 3 STAFFING Standard No Score 27 3 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 3 Abbotsleigh Mews Nursing Home DS0000006751.V250491.R01.S.doc Version 5.0 Page 24 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(2) Requirement Clear information about the GP’s agreement to the administration of homely remedies to residents must be made available to staff in Calvin House. The medication fridge in Calvin House must be maintained at a safe temperature. Full risk assessments must be undertaken for residents who manage their own medication. The celing in the shower room in Macmillan House must be painted and loose tiling secured. Residents must have their own, individual supplies of washing/skin creams. The call bell in room 5 of Macmillan House must be properly fitted to the wall. Timescale for action 01/02/06 2 3 4 5 6 OP9 OP9 OP19 OP26 OP38 13(2) 13(2) 23(2) 12(1) 23(2) 01/01/06 01/02/06 01/03/06 01/12/05 01/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Abbotsleigh Mews Nursing Home DS0000006751.V250491.R01.S.doc Version 5.0 Page 25 No. 1 2 3 4 5 6 7 8 9 10 11 12 13 Refer to Standard OP4 OP7 OP8 OP9 OP9 OP12 OP15 OP15 OP26 OP27 OP27 OP36 OP38 Good Practice Recommendations Application should be made for variation in the home’s registration in relation to those residents in the nursing units who are diagnosed as suffering from dementia. Residents should have care plans for social interaction and activities. Records of wound care should be comprehensive and easy to follow. Bedroom doors should be locked when requested by residents/relatives. Consideration should be given to providing net curtains to bedroom windows. The activities budget should be reviewed. Residents in Calvin House should be offered a choice of meal and an alternative meal if they do not wish to eat one of the main meals on the menu. Residents should be provided with plate guards, where necessary. Wheelchairs should be kept clean. The staffing levels in Calvin House, agreed when the home was originally registered, should be increased, in response to the changing needs of residents. The amount of designated management time for each unit should be reviewed. Staff supervision should take place six times a year and cover those issues listed under this standard. Staff should ensure that call bells are answered promptly at night. Abbotsleigh Mews Nursing Home DS0000006751.V250491.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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 Abbotsleigh Mews Nursing Home DS0000006751.V250491.R01.S.doc Version 5.0 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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