Inspection on 11/11/05 for Abercarn Residential Home

This inspection was carried out on 11th 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.

Other inspections for this house

Abercarn Residential Home 21/10/09

Abercarn Residential Home 29/07/09

Abercarn Residential Home 04/11/08

Abercarn Residential Home 15/11/07

Abercarn Residential Home 19/01/07

Abercarn Residential Home 27/01/06

Abercarn Residential Home 11/03/05

Abercarn Residential Home 06/07/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Abercarn Residential Home 56 High Street Pensnett Dudley West Midlands DY5 3AW Lead Inspector Mr Jon Potts Unannounced Inspection 11th November 2005 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Abercarn Residential Home DS0000024968.V265487.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. Abercarn Residential Home DS0000024968.V265487.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Abercarn Residential Home Address 56 High Street Pensnett Dudley West Midlands DY5 3AW 01384 480059 01384 480059 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) Cotdean Nursing Homes Ltd Miss Sarah Phillips Care Home 32 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (1), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (3), Old age, not falling within any other category (20), Physical disability (1), Physical disability over 65 years of age (7) Abercarn Residential Home DS0000024968.V265487.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11/2/05 Brief Description of the Service: Abercarn is a double fronted detached house located in the heart of Pensnett on a main route between Kingswinford and Dudley, this served by a bus route. It provides accommodation for 32 service users on two floors. The home has two assisted bathrooms, one on the ground floor and one on the first. There is a lift, which provides access to all parts of the communal areas. On the ground floor, the home has a large through lounge and dining room, the Manager ’s office located to the corner of the dining room. There are a number of bedrooms on the ground and first floor, and number of these shared. The home boasts a large garden area at the rear of the property. There are car parking spaces to the front and side of the property. Abercarn Residential Home DS0000024968.V265487.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried out between 9.30am and 5.30pm and involved two inspectors. Evidence was gathered through case tracking four residents care, this including discussion with the residents themselves. Further evidence was gained from sight of such as staffing files, policies and procedures, health and safety documentation, medication records and menus. There was some observation of staff practices and inspection of some areas of the building. The acting manager and a senior manager were also involved in the inspection as well as some of the staff team. All those involved in the inspection are to be thanked for their forbearance and assistance. What the service does well: What has improved since the last inspection? What they could do better: There are a number of areas where improvement is required this including better documentation within care plans as to the residents individual Abercarn Residential Home DS0000024968.V265487.R01.S.doc Version 5.0 Page 6 preferences and information that is always consistent with risk assessments (suggesting a lack of update). There also needs to be consistent evidence of residents involvement within the care planning process. Residents must be offered access to dentists and opticians in accordance with individual choices. Medication must also only be given when prescribed and any medication not given to residents disposed of safely as well as consistently signed in when received. Residents choices in respect of individual preferences must be better documented and activities offered in accordance with these, and the choices of the residents as a whole. Staff are in need of training in respect of adult protection and all staff must be subject to an enhanced disclosure. The premises require redecoration in areas and this needs to be reflected in a timed programme that shows forward planning. There are a number of areas where redecoration must be prioritised. There is still a need to ensure that there are consistently two references for staff employed at the home, and that all staff are supervised at least six times per annum. Clarification is still to be sought in respect of the servicing of the parker bath and cleanliness in the dining room could be better. The homes quality assurance system still needs to be developed, this so that findings from consultation exercises are appropriately actioned and the home can better demonstrate it methods for self-assessment. 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. Abercarn Residential Home DS0000024968.V265487.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 Abercarn Residential Home DS0000024968.V265487.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): 1,2,3 Prospective and current residents have access to information about the home, this to assist them in making an informed choice. Most residents have a written contract/terms and conditions with the home although not all have signed these. Resident’s needs are assessed prior to their admission to the home, and the home confirms its ability to meet needs, but not always to the resident. EVIDENCE: The home’s statement of purpose and service user guide has been subject to some review since the last inspection and there was clear evidence that these documents were readily available to residents and visitors with copies of the former in the home’s foyer and the latter in the residents’ bedrooms. The home’s terms and conditions/contracts were also revised and residents recently admitted had been given copies of the revised document. The copies of contracts seen were mostly signed either by the residents or their Abercarn Residential Home DS0000024968.V265487.R01.S.doc Version 5.0 Page 9 representatives, although there was one seen that wasn’t. An appropriate person must sign the contract. From sight of case files it was clear that the home was in receipt of assessments carried out by social workers prior to admission, these in part forming the basis for the homes care plans. These assessments were complimented by the homes own assessments and there was evidence of the home confirming it was able to meet the needs of residents prior to admission, although one of the letters seen was not addressed to the resident. Abercarn Residential Home DS0000024968.V265487.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 The resident’s health, personal and social needs are detailed in care plans that are not consistently up to date or agreed by residents/representatives. Resident’s health care needs, with the exception of access to dentists and opticians at appropriate intervals, are met. There are some areas where the systems for the protection of residents in respect to administration of medication have been compromised. Residents, with limited exceptions, feel they are treated with respect and have their privacy upheld. EVIDENCE: Care plans were found to be in place in respect of all the residents’ files that were case tracked, these generally clear, subject to monthly review and covering areas in respect of physical, social and emotional care. Whilst improved since the time of the last inspection there is still scope for continued development. The following examples illustrate areas where such improvement is to be targeted: Abercarn Residential Home DS0000024968.V265487.R01.S.doc Version 5.0 Page 11 - One care plan stated that the resident was at high risk of falls. The statement in the homes falls risk assessment contradicted this showing that the care plan had not been updated, as other evidence showed the falls risk assessment to be correct. - Not all care plans referenced (in respect of personal hygiene) whether the resident preferred a bath or shower, whether there was preferences in respect of religious observance or the types of food the resident would choose. - There was no information in one care plan in respect of how to communicate with a resident who had limited verbal speech. The acting manager was clearly aware of how this should be managed however (though use of the resident having a note pad and pen) and there was information in the original assessment. - Some but not all of the case files contained a sheet signed by the resident or the representative stating that they did not wish to have involvement in the care planning process. Wherever possible residents or their representatives should be encouraged to have this involvement. Residents were assisted to access their G.Ps as needed although there is a need to ensure that there is at least annual access to dentists and opticians or some record as to the resident’s preferences in respect of access to these services. All case files were seen to contain appropriate risk assessments in respect of falls, tissue viability and moving and handling, these updated on a regular basis. Nutrition risk assessments (not titled as such) were present but carried no reference to diabetes or special diets. Weights, whilst not always taken monthly, were seen to be documented. An inspector observed the administration of medication this seen to be carried out appropriately with the exception of the disposal of prescribed medication. The inspector observed a tablet being dropped on the floor. A replacement tablet was given from the pack however it was discovered staff destroyed this tablet by putting it down the toilet and not in accordance with the homes policy. Whilst records were seen to be generally well documented and consistent with G.Ps directions there was concern that the medication seen to be dropped and disposed of was not recorded as such. There was also an issue where a resident was given oxygen due to having severe breathing difficulties. This resident was not prescribed oxygen and at the time of the inspection it was stated by the acting manager that permission was not sought from the G,P. until after it had been administered. This was the subject of an immediate requirement. It was also noted that based on the records seen not all staff are recording the receipt of medication as must be the case. Staff that administer medication have received the appropriate accredited training. Some residents spoken to indicated that they would like to have a lock to their bedroom door, these needing to be fitted as needed. The registered provider needs to ensure that all residents are asked in respect of this choice, and Abercarn Residential Home DS0000024968.V265487.R01.S.doc Version 5.0 Page 12 appropriate action taken to fit locks where this is requested. There was also discussion with one resident who had cotsides who was clearly unhappy with this arrangement, this matter not subject to a risk assessment. With the exception of these issues there were no other concerns observed or expressed by the residents as to how staff upheld and respected their privacy and dignity with numerous positive comments from residents as to the attitude and friendliness of the staff group. Abercarn Residential Home DS0000024968.V265487.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 There is a lack of clarity in some cases as to what resident’s expectations and preferences are, and there is limited recreational opportunities available. Residents are able to maintain contact with family, friends and representatives. Resident’s views of the quality of the food available vary and the surroundings in which residents eat would benefit from improvement. EVIDENCE: The reader’s attention is drawn to earlier comments where care plans do not always specify what the resident’s wishes are in respect of their preferences and expectations. In addition to areas already mentioned (bathing, meals etc) there should be clear information as to preferred times of rising, retiring, routines. In addition whilst there was some evidence of activities these were limited with no evidence seen first hand during the course of the inspection. It was disappointing to see staff, whilst sitting in the lounge to supervise residents, were sat talking to each other on more than one occasion, rather than talking to the residents. Despite this residents spoken to expressed satisfaction with life at the home, although residents at their last meeting on the 20/6/05 raised the need for more activity. There was some evidence that some residents are Abercarn Residential Home DS0000024968.V265487.R01.S.doc Version 5.0 Page 14 assisted to carry on their chosen religion, although documentation in respect of religious preferences was not detailed in all case files. The home was seen to have a visitor’s policy that stipulates there is no restriction on visiting. There was seen to be a number of relatives visiting the home during the course of the inspection. The majority of the questionnaires sent to relatives by the home in June/July 2005 indicated that they were offered hospitality. From sight of the meal records there was evidence that residents were offered choices in respect of the foods they were provided, this confirmed by the comments made to inspectors by residents. The menus were seen to be on display in the lounge these now including the suppertime menus. Based on these a balanced diet is available to residents, and comments made by residents directly to inspectors in respect of the meals indicated that they enjoyed these. Comment made by residents in the lounge after, this overheard by an inspector, indicated that two residents were dissatisfied with the lunch time meal, one as they were not offered an agreeable alternative to the main meal and the other complaining about the chips which were said to be ‘too hard to eat’. The residents meeting on the 20/6/05 indicated that residents wanted a wider choice of meals and puddings. The homes dining area would also benefit from redecoration so as to make it a more congenial environment in which to eat. Better table clothes and better standards of cleanliness would also help with it noted that some condiments had dried sauce on and there were still crumbs on one tablecloth at lunchtime from the previous meal. Abercarn Residential Home DS0000024968.V265487.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 Residents and their relatives are aware of the homes complaints procedure with some confidence expressed in the staff ability to address these. There have been instances since the last inspection where residents have not been protected from abuse, this a matter from which the management have learnt lessons. EVIDENCE: The homes complaints procedure was seen to be on display in the homes foyer, although could be positioned for better access. The majority of the respondents to the homes last customer satisfaction survey forms did however indicate that they were aware of the homes complaints procedure. Residents spoken to also stated they were aware of whom to complain to, with some saying that any issues raised were addressed. The acting manager should however be picking up all issues of concern and logging them as complaints, this to demonstrate on one hand that they are proactively pursuing all issues of concern, and on the other recording evidence which would provide useful should the matter be referred to outside bodies. There has been one complaint since the time of the last inspection, this investigated by the CSCI and partly upheld. Other issues of concern raised later around similar issues led to the instigation of the local authorities vulnerable adults procedures. Following this second investigation the provider took appropriate action to address areas of concern although this has highlighted the need for the company to be proactive in identifying and dealing with practices that may result in abuse, unintentional or otherwise. It is due to the provider’s involvement in the recent Abercarn Residential Home DS0000024968.V265487.R01.S.doc Version 5.0 Page 16 vulnerable adults protection investigation that the inspector knows they are now aware of the correct procedures to follow. The homes procedures in respect of adult protection and related issues were found to be acceptable with the exception of the violence and aggression which makes reference to use of ‘bear hugs’ which contradicts the homes no restraint policy. Staff also need to have training in adult protection, this stated to be planned. Copies of local authority procedures were seen to be available in the home. There are some issues in respect of some existing staff not been subject to enhanced disclosures and recording of resident’s property on admission (see management and administration). Abercarn Residential Home DS0000024968.V265487.R01.S.doc Version 5.0 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 the following standard(s): 19,23 Residents live in a safe environment that could be better maintained in some areas. Not all residents have access to locks to their bedroom doors where this was an expressed wish. EVIDENCE: Overall the home offers a comfortable living environment although there are some key areas that needs attention, this including the dining area and the corridors (this due to damage to borders which make them look uncared for). There was also a toilet off the lounge area, which was blocked at the time of the inspection. The exterior of the property also needs repainting. The provider has produced a programme of works, this only identifying those works that have been carried out since the last inspection, not a forward plan of those areas that need attention. This plan did show that a number of bedrooms have been redecorated since the last inspection. Abercarn Residential Home DS0000024968.V265487.R01.S.doc Version 5.0 Page 18 On a positive note, following a fire prevention officer’s visit, where areas of serious concern were raised, the provider has worked with the fire officer to address these matters. Sight of the last environmental services report (from a visit on the 28/7/05) and a brief inspection of the kitchen area did show that the requirements are now partly met. One resident spoken to did express some concern as to the size of their room (due to their specific needs), although the acting manager was aware of this and there were plans to move her to a larger bedroom in the near future. A number of residents stated that they would like locks to their bedrooms doors this as mentioned earlier in the report. From discussion with residents it was clear that they are able to bring in their own furniture and possessions within space and safety constraints. Abercarn Residential Home DS0000024968.V265487.R01.S.doc Version 5.0 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 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): 27,28,29,30, There is sufficient allocated care staff to meet the needs of the residents accommodated at the time of the inspection. The safety of the staff recruitment process is compromised by the lack of some recruitment checks. Staff are generally well trained and there is on-going training in place that will ensure staff are sufficiently trained to be competent to do their jobs, and that residents are in safe hands at all times. EVIDENCE: Based on the calculation of staffing levels with use of the residential forum staffing tool the home has sufficient care staff available, this translating into five carers during the morning period, four in the afternoon and three waking night staff. In addition to care staff there are also ancillary staff available (cooks, domestics etc). It was noted that staff are available in the lounge area more frequently than seen at the last inspection. An audit of three files for some recently employed staff was carried out this showing that they were gaps in respect of the recruitment checks and information that must be carried out this including the following: Abercarn Residential Home DS0000024968.V265487.R01.S.doc Version 5.0 Page 20 - No record of the date the staff commenced work at the home. - In one case only one reference and another no reference from the last employer. They must be a minimum of two references one which must be from the last employer, and where appropriate the last social care employer. - There was no evidence of enhanced disclosures for a number of staff (this confirmed as 13 of the staff by the provider post inspection). All staff must be subject to a disclosure. Where staffing levels dictate that the home needs to employ staff without a disclosure all other recruitment checks must be carried out (including a POVA first) and a risk assessment completed, this to be discussed with the CSCI prior to the staff member starting employment. - There was one file without a photograph of the staff member. All other required information not detailed above was present and it was pleasing to see that application forms did contain details of the staff member’s full working histories. The home was seen to have a training planner that clearly identified what training staff held, and what was needed. Based on this staff were seen to require training in adult protection, this stated to be planned. It was of note that the provider has invested in a number of training courses for staff since the last inspection and whilst there is less than 50 of staff with NVQ 2 at this time (7 out of 16 staff hold the qualification) seven staff are currently undertaking this training. There was clear evidence of recently employed staff commencing the Skills for care (formerly TOPSS) induction programme although the provider should be aware that expectations in respect of the induction and foundation training have recently been revised. Abercarn Residential Home DS0000024968.V265487.R01.S.doc Version 5.0 Page 21 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 Management arrangements need to be kept under review. The home needs to better demonstrate how it is run in the best interests of the residents. Resident’s financial interests are generally well safeguarded. Not all staff are appropriately supervised. Overall the health, safety and welfare of the residents are promoted although there are a few areas where safety is compromised. EVIDENCE: The home currently has an acting manager that is closely supervised by an experienced manager from another home. Due to circumstances the company Abercarn Residential Home DS0000024968.V265487.R01.S.doc Version 5.0 Page 22 is not in a position to put forward an application for a manager’s registration for the home at this time, although is keeping the CSCI informed of matters in respect of this issue, which is to be kept under regular review by the CSCI. The home does not have a professionally recognised quality assurance tool but there is evidence that service user and relative views about the standard of care are formally sought. This should now be extended to include other stakeholders. Residents’ written comments were largely complimentary about the service. The opinions collated are not being published or made available to interested parties and the home needs to make use of feedback and evidence how this influences practice. There is not a development plan in place to ensure that such improvements are made. A spot check was carried out on four of the resident’s monies in safekeeping, these all found to be correct when compared to well documented records. In addition there was seen to be regular audits of residents monies. Where residents wish they were able to manage their own financial interests. The only concern was in respect of some of the resident’s inventory forms, which were noted not to have been completed. From sight of staff files it was noted that there was a lack of evidence to show all staff are supervised six times per annum. There is a good range of risk assessments in place to reduce risks identified within the environment covering slips, trips and falls, electrocution, clinical waste, cuts due to sharps, chemical storage, drowning, falls from bed and lifting of clients etc. Maintenance and service documentation was sampled and the following omissions were identified: • It was unclear as to whether the Parker bath had been serviced to expected frequencies. Individual risk assessments are commented on earlier in the report, although it was of concern that one resident using cotsides was not risk assessed. The accident records were examined, this raising no concerns with no identified trends or patterns. Earlier comments in respect of the cleanliness of the dining area are to be noted. There are still some areas outstanding from the last Environmental services report, the home working towards addressing these. Any issues in respect of fire safety have been addressed with the fire prevention officer. Abercarn Residential Home DS0000024968.V265487.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 3 2 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 1 2 X X X 2 X X X STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X 2 2 X 2 Abercarn Residential Home DS0000024968.V265487.R01.S.doc Version 5.0 Page 24 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 OP7 Regulation 13(4) Requirement Where cotsides are in use there must be a risk assessment in place, this identifying measures put in place to reduce risk and to assess whether the individuals choice as to the use of this device outweighs the risks presented. To ensure that residents or their chosen representative’s involvement is consistently evidenced by signature within the case file. To ensure that information in individual risk assessments does not contradict the information recorded in their care plans, and that when a risk assessment is updated the care plan is as well. To ensure that all residents are offered access to a dentist and optician at least annually, or their choices in respect of not accessing these services to be documented and agreed with them. No residents are to be given prescribed medication unless you have the express permission of DS0000024968.V265487.R01.S.doc Timescale for action 31/12/05 2 OP7 15 31/01/06 3 OP7 13 & 15 31/12/05 4 OP8 13(1)b 31/01/06 5 OP9 13(2) 11/11/05 Abercarn Residential Home Version 5.0 Page 25 the residents G.P. This was an immediate requirement. Medication must also be disposed of in accordance with the homes policy and consistently signed in when received at the home. To ensure there is better and more precise information in care plans as to resident’s individual choices in respect of religion, bathing, food preferences, dayto-day routines and activities. An activities programme must be produced that contains activities that are based on the resident’s preferences as identified within residents meetings and individual assessments. This is a repeated requirement that should have been meet by the 1.4.05. All residents are to be offered a choice of meals prior to their serving and their choices clearly recorded. All staff must be provided with training in adult protection and the action to take if witnessing abuse. All staff must be subject to an enhanced disclosure. This was an immediate requirement. To develop a programme of maintenance and renewal for the premises that identifies timescales for work to be completed. This to include: -Redecoration of the dining area, replacement of the flooring and replacement of the compromised window panel in the double DS0000024968.V265487.R01.S.doc 6 OP12 12 & 15 28/02/06 7 OP12 16(2)m 31/01/06 8 OP15 12 & 16 31/12/05 9 OP18 13(6) 31/12/05 10 OP18 19 31/12/05 11 OP19 16 & 23 31/12/05 Abercarn Residential Home Version 5.0 Page 26 glazed patio door. - Redecoration of the exterior of the home. - Replacement of vinyl flooring in bathrooms and toilets where needed. - Redecoration of corridors as needed. Elements of this requirement are repeated from the last inspection. Where residents wish to have a lock fitted to their bedroom, these must be provided. Two suitable references must be obtained prior to employment of any staff This is a repeated requirement that should have been met by before this inspection. The date a member of staff starts work at the home must also be recorded in their file. To implement a quality assurance and monitoring system. 12 13 OP24 OP29 16 19 31/01/05 30/11/05 14 OP33 35 28/02/05 15 OP35 13 & 17(2) 18 23 16 17 OP36 OP38 This is a repeated requirement that is partly met. See comments in the body of the report. Inventories of resident’s property 30/11/05 must be consistently completed on admission and then reviewed on a regular basis. To ensure all staff are formally 30/03/05 supervised at least six times per annum. The manager must clarify with 30/11/05 environmental services as to the expected servicing schedule for the Parker bath. This is a repeated requirement that was to have been met by Abercarn Residential Home DS0000024968.V265487.R01.S.doc Version 5.0 Page 27 18 OP38 23 the 15.3.05. Care must be taken to ensure satisfactory standards of cleanliness in the dining area. 30/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP3 OP8 Good Practice Recommendations To ensure all residents have access to an annual review of their care, this through liaising with the appropriate commissioning department where necessary. To ensure that nutritional assessments carry clear reference to diabetes (where appropriate) and that residents are weighed in accordance with the frequencies specified in the homes own guidance. To clearly identify nutritional assessments in case files as such (through the addition of a clear title) The bathing record should be competed with greater accuracy. Staff when sat in the lounge should not be talking with each other, but interacting with residents. Any concerns raised within forums such as resident’s reviews should be documented as complaints in the homes complaints records, with clear detail as to the action taken to address them. To continue with the training of staff in NVQ level 2 so as to allow the home to have 50 or more staff so qualified. To continue working towards addressing all issues raised in the last environmental services report. 3 4 5 6 OP8 OP8 OP12 OP16 7 8 OP28 OP38 Abercarn Residential Home DS0000024968.V265487.R01.S.doc Version 5.0 Page 28 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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 Abercarn Residential Home DS0000024968.V265487.R01.S.doc Version 5.0 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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