Inspection on 20/06/07 for Aberry House

This inspection was carried out on 20th June 2007.

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

Aberry House 22/04/08

Aberry House 04/12/07

Aberry House 25/07/06

Aberry House 19/09/05

Aberry House 07/06/05

Aberry House 17/02/05

Aberry House 23/08/04

Similar services:

Applegarth

Trevayler Residential Care Home

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

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

CARE HOMES FOR OLDER PEOPLE Aberry House 6 Monsell Drive Leicester Leicestershire LE2 8PN Lead Inspector Diane Butler Unannounced Inspection 20th June 2007 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 Aberry House DS0000006356.V339986.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. Aberry House DS0000006356.V339986.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Aberry House Address 6 Monsell Drive Leicester Leicestershire LE2 8PN 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) 0116 2915602 0116 2915603 Mrs Margaret Madden Mrs Debra Ann Robinson Care Home 35 Category(ies) of Dementia - over 65 years of age (18), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (18), Old age, not falling within any other category (35), Physical disability over 65 years of age (6), Sensory Impairment over 65 years of age (4) Aberry House DS0000006356.V339986.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service user numbers. No person falling within category SI(E) may be admitted to the home when 4 persons who fall within category SI(E) are already accommodated within the home. Service user numbers. No person falling in category MD(E) or DE(E) may be admitted to the home when 18 persons who fall within category/combined categories MD(E) or DE(E) are already accommodated within the home. Service user numbers. No person falling within category PD(E) may be admitted to the home when 6 persons who fall within category PD(E) are already accommodated within the home. Service user numbers. Persons who fall within registration category PD(E) can only be accommodated in rooms numbered (at the time of registration) 7-20 and 22. To be able to admit the named person under the age of 65 years named in the variation application number V25761. Named Person To be able to admit a named person under the age of 65 years named in variation V30998 dated 28 March 2006 9th November 2006 2. 3. 4. 5. 6. Date of last inspection Brief Description of the Service: Aberry House is a care home for older persons, providing accommodation and personal care for up to thirty eight residents. The home is situated on a quiet street off the main Lutterworth road in the city of Leicester. Accommodation is on two floors with the upper floor accessed by lift or stairs. There are four lounges and a dining room on the ground floor. The home offers thirty six single bedrooms and one shared bedroom, all but one of these rooms offer ensuite facilities. The room without ensuite facilities has a toilet close by. A well-maintained secure garden is situated to the rear of the home. Current charges range from £380.00 per week to £580.00 per week. Additional charges are in place for hairdressing, chiropody treatment and transport to appointments. Details of all charges can be found in the homes Statement of Purpose document, which is given to all prospective and current residents. A copy of the most recent CSCI (Commission for Social Care Inspection) report is displayed in the office area and is available to all residents and visitors. Aberry House DS0000006356.V339986.R01.S.doc Version 5.2 Page 5 Aberry House DS0000006356.V339986.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit, which took place over a six and a half hour period on Wednesday 20th June 2007. When undertaking key inspections the Commission for Social Care Inspection (CSCI) focuses on the outcomes for residents living in a home. In order to do this, the inspector ‘case tracked’ four residents. This means the inspector checked their care records and met with them and their relatives where possible. Where communication was difficult, observation was used to evidence whether care needs were being met. A further three residents and seven relatives were also spoken with to gather their views of the home. The inspector talked with three members of staff on duty at the time of the visit and observed them going about their daily work. Pre inspection documentation received since the last inspection and the last inspection report have also been taken into account when producing this report. Questionnaires were sent to a selection of residents and their relatives to gain their views of the agency and three GP practices were contacted to enable the inspector to gather their views of the service being provided. Comments received included: “I received a document which was described as a Statement of Purpose, which details aims, objectives, provisions of care, policies regarding termination of residency and so on. All the contents are perfectly reasonable and acceptable”. “We inspected several homes before making a decision, we had a long discussion with the owner prior to my relatives admission”. “Our relative always appears well cared for when I visit daily”. “Food, drinks, medicines, mealtimes and night duty are all high quality”. “This home is very well run”. “The meals appear adequate, varied and tasty”. “I usually speak to a senior carer or the manager if concerned about anything but the junior staff are receptive and able to help”. Aberry House DS0000006356.V339986.R01.S.doc Version 5.2 Page 7 “The home seems to be well staffed”. ““The staff are friendly and polite and very patient”. What the service does well: What has improved since the last inspection? What they could do better: Aberry House DS0000006356.V339986.R01.S.doc Version 5.2 Page 8 Ensure that the care plan documentation is kept up to date, care workers need to have up to date information to enable them to care properly for the residents. Ensure that all identified risks are included in the risk assessment documentation and keep these under review. Care workers need to be aware of all the current risks to the residents and the actions to take to minimise those risks. Ensure that any suspected acts of abuse are appropriately referred under safe guarding adults protocol and ensure that all staff are aware of their responsibilities around adult protection. The residents need to be protected from any possible acts of abuse. Ensure that recruitment procedures are adhered to. Residents need to be protected by the recruitment procedures that are in place. Ensure that the CSCI is notified under regulation 37 of any death, illness or other events, which adversely affect the well being or safety the residents. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Aberry House DS0000006356.V339986.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Aberry House DS0000006356.V339986.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,5,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their relatives are given relevant information about the home and are able to look around before deciding whether it is the right place for them. EVIDENCE: A Statement of Purpose document and a Service User Guide are available to all prospective and current residents. Details included in these documents, which have recently been reviewed, include the aims and objectives of the home, what services can be provided and the terms and conditions of residency. The registered provider stated that she visits all prospective residents to carry out a needs assessment and to discuss what the home has to offer. Aberry House DS0000006356.V339986.R01.S.doc Version 5.2 Page 11 All prospective residents and/or their relatives are also invited to look around the home and stay for lunch if they wish, this enables them to get a flavour of life in the home and whether it would be the right place for them to live. Seven relatives spoken with all confirmed that they had received information about the home and that they were able to look around before their relative moved in. Comments received included: “We came to have a chat first, then brought mum to have a look around”. “I looked around before my relative moved in, as soon as I came I knew it was the right place”. “They went to see here in hospital, before she moved in”. The files belonging to the four residents case tracked were checked and were found to include an initial assessment completed by the registered provider. One file also included the needs assessment prepared by their social worker and one included relevant information from the previous residential home where they had lived. The registered manager explained that intermediate care had been provided in the past, though this was not currently being provided. Aberry House DS0000006356.V339986.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are looked after well in respect of their health and personal care, however, risk assessments and care plans need to be more thorough and kept up to date to ensure that their health and welfare are not put at risk. EVIDENCE: Care plans and risk assessments were in place for the four residents who were case tracked. A care plan summary is also used so that the care workers can see at a glance what the individual needs of each resident are. All the care workers spoken with on this occasion confirmed that they read the care plans on a regular basis to ensure that they were up to date with the residents needs. The home currently uses a document entitled ‘needs assessment’ as their care plan document. It is recommended that this be changed to avoid any confusion to the reader. Aberry House DS0000006356.V339986.R01.S.doc Version 5.2 Page 13 It was noted that not all had been reviewed on a monthly basis and for one resident who regularly displays challenging behaviour their care plan and risk assessment had not been reviewed for three months. It was also noted the risk assessment didn’t fully reflect or address the risks presented to the care workers on a daily basis. One care worker explained that she had been hit on three occasions recently. The registered manager stated that this would be addressed immediately. On checking the care plan of another resident case tracked it was noted that although the resident had moved into the home on 23/04/07 the care plan had not been completed until 07/05/07 and their risk assessment had not been completed until 24/05/07. On checking the risk assessment documentation it was noted that not all risks were included including the risks to a resident who suffers from epilepsy. Moving and handling assessments were in place though these had not been updated. On checking the daily records it was evident that the residents have access to appropriate healthcare professionals including the community nurse and the local GP. The medication records and blister packs belonging to the four resident’s case tracked were checked and were found to be in order, though on checking the eye drops used by one of the residents case tracked it was noted that these had not been dated when opened. By dating the bottle it enables the user to know when the eye drops should be destroyed as they have a limited shelf life once opened. All residents and/or their relatives spoken with on the day of the visit stated that they were treated with respect and their care and support needs were being met. Comments received included: “It is very good care here”. “If they aren’t happy about something they will get the doctor out and let me know, there’s no hesitation”. “The staff are very good, very good indeed”. Throughout the inspection the inspector observed care workers interacting with residents in a positive and dignified manner. Aberry House DS0000006356.V339986.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are given opportunities for stimulation through activities both in and outside of the home. EVIDENCE: Choices are offered on a daily basis including whether to stay in bed or get up, what to eat and where to eat it, and whether or not to join in the activities provided. One relative explained, “Margaret (the registered provider) said, what ever you want to do, you can do”. An activities leader has been employed since the last inspection to provide activities and one to one support throughout the week, when the activities leader is not at the home the care workers are asked to provide the activities and support. Aberry House DS0000006356.V339986.R01.S.doc Version 5.2 Page 15 Activities provided include craft work, sewing and knitting, board games, aromatherapy, jigsaws make up and beauty and flower arranging. A number of trips have been arranged and a group of the residents are due to attend a picnic the week following the inspection. Positive comments have been received from relatives regarding the new activities leader and the work she is doing with the residents. Comments seen include: “xxx (the activities leader) is worth her weight in gold, what more can I say”. “Came to the home on Wednesday and xxx had taken two residents for a walk out side and they liked it very much, then she took a lady out in a wheelchair the residents enjoyed it very much”. “The activities are excellent, very enjoyable”. Family and friends are encouraged to visit. Relatives and visitors spoken with during the inspection confirmed that they were made most welcome and were able to visit at any time. One relative explained, “We are always made welcome and offered a cup of tea”. A second relative stated, “they are very welcoming and very good”. All residents spoken with stated that the food served in the home was good, and they were offered a choice at all times. During the inspection one of the residents stated that they didn’t want what was offered but wanted a cheese sandwich instead, the senior in charge spoke with one of the care workers and a cheese sandwich was made. Questionaires received from relatives prior to the inspection visit also included positive comments about the food provided. Aberry House DS0000006356.V339986.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Although residents feel safe living in the home, staff’s lack of understanding in adult protection procedures could potentially put them at risk. EVIDENCE: A complaints procedure is in place and all residents and/or their relatives spoken with were aware of who to talk to if they werent happy about something. One relative explained, “I would talk to Margaret (registered provider) she’s very approachable and sorts any problem out”. A relative questionaire received prior to the inspection visit explained, “Felt the need to write to Margaret about my mums care, it was resolved immediately, very happy with outcome”. A relative also shared that previously their relative hadn’t looked well cared for, though as soon as something was said it was addressed. Pre inspection documentation received prior to the inspection visit stated that five complaints have been received and two adult protection investigations have been carried out in the last twelve months. This statement was supported on checking the complaints file and on speaking with both the registered provider and the registered manager. Aberry House DS0000006356.V339986.R01.S.doc Version 5.2 Page 17 The adult protection issues involved the behaviour of one resident to another and an accident that a resident was involved in. These were investigated and actions were taken to address any shortfalls identified. The complaints, which included a complaint about there being no horlicks available, another because it was felt that the water provided wasn’t fresh and another which involved the overall care of a resident were also looked into and where necessary actions taken to ensure the issues didn’t arise again. On checking the daily records belonging to one of the resident’s case tracked it was evident that an altercation had occurred with another resident two days prior to the inspection visit. It was noted that although the residents GP had been contacted with regard to the changing of their medication the incident had not been referred under the safe guarding of adults protocol and a regulation 37 notification had not been sent to the CSCI (Commission for Social Care Inspection) to inform them of the incident. An Immediate Requirement was left with regard to this issue and the registered provider informed all parties immediately. All residents and/or their relatives spoken with stated that they felt safe living at the home and they were well looked after. One relative stated, “I feel she is very safe here”, another relative explained, “I feel she is as safe as she is going to be”. A resident spoken with stated, “yes I feel safe, I would soon say something if I didn’t”! On speaking with the care workers on duty during the inspection visit not all were thoroughly aware of the actions to take should they witness or suspect an act of abuse. Whilst one stated that they would speak to the manager immediately another stated that they would observe the resident but would keep quiet. However, when asked again the care worker said that she would tell a senior. This was discussed with the registered provider who stated that she could understand why a care worker had said this because some carers were feeling a little intimidated by other staff. The inspector was informed that this was being dealt with. The registered provider must ensure that all care workers know how to and act on any suspicion of abuse. It was recommended that all care workers be reminded of their responsibilities around adult protection without delay. The inspector was informed that Multi Agency Adult Protection training has been booked for July and August and all staff will be attending this. Aberry House DS0000006356.V339986.R01.S.doc Version 5.2 Page 18 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): 19,20,24,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided with a comfortable and homely place to live. EVIDENCE: A new extension has recently been built. This provides a further three single ensuite bedrooms to add to the exisitng accomodation which offers thirty two single ensuite rooms, a further single bedroom without ensuite and one double ensuite room. The room without ensuite facilities has a toilet close to the room. A new lounge/dining room has also been provided within the new extension which enables the residents to meet with their visitors in private if they don’t wish to go to their own rooms. Aberry House DS0000006356.V339986.R01.S.doc Version 5.2 Page 19 The areas of the home seen on this occasion were well maintained and suited to the residents needs. Decoration in the home is of a good standard and furnishings in the communal areas are domestic in character and in good condition. The room belonging to one of the resident’s case tracked was seen. This was clean, appropriately furnished and included the residents personal belongings. All residents and/or their relatives spoken with were most satisfied with the accommodation provided. A new disabled shower room and toilet is near completion and a number of the resident’s ensuite facilities have been redecorated and updated. There is a delightful secure garden area to the rear of the home. This has recently been fitted with a ramp and handrails are due to be fitted in the next few days. This will enable all the residents living at the home to have access to the garden area. Comments included in relative questionnaires received prior to the inspection visit stated: “Cleanliness is excellent” “Dining room, lounge, bedroom carpets need cleaning” “The home is warm, comfortable, and welcoming. It is well furnished and clean”. Aberry House DS0000006356.V339986.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): 27,28,29,30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Although staff are appropriately trained, current recruitment practices could potentially put residents at risk. EVIDENCE: There were sufficient numbers of staff on duty on the day of the visit to meet the current needs of the residents. Residents and/or their relatives spoken with felt that on the whole there were enough staff on duty to meet their individual needs and the care workers spoken with felt that there were normally enough staff on each shift to care properly for the residents, but this very much depended on the sort of day the residents were having. All residents and/or their relatives spoken with confirmed that their current care needs were being met and on speaking with three care workers on duty during the visit it was evident that they were aware of the individual needs of the four residents case tracked. Aberry House DS0000006356.V339986.R01.S.doc Version 5.2 Page 21 Three staff files were checked. It was noted that for one of the care workers who was employed in April this year, a CRB or POVA 1st had yet to be collected. The registered manager explained that this care worker had worked for them previously, when a CRB had been requested, they then left their employment but returned in April this year. On checking their employment details it was noted that it had been over a year since they had worked at the home. The registered manager stated that a CRB and Pova 1st check would be requested immediately. All three had references in place though it was noted that the majority of these were character references. All three care workers had completed an in house training session and were due to start formal induction devised by ‘Skills for Care’ (an external training organisation) in the near future. A large number of training sessions have been provided since the last inspection including: Moving and Handling First Aid Food Hygiene Fire Awareness Dementia Awareness Palliative Care COSHH Dealing with Challenging Behaviour. Care workers are currently completing infection control training and abuse awareness training is booked for July and August this year. Aberry House DS0000006356.V339986.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The health and safety of the residents is promoted, however shortfalls within recruitment and protection could leave residents at risk. EVIDENCE: The registered manager has many years experience in care and has completed her NVQ level 4 and Registered Managers Award. Evidence was also seen during the visit of her completing a number of training courses to update her knowledge and skills. Aberry House DS0000006356.V339986.R01.S.doc Version 5.2 Page 23 It was noted during the inspection that there were shortfalls within the homes recruitment process, procedures for the protection of the residents and within the risk assessment documentation. On speaking with the registered manager the inspector was informed that these issues would be addressed. All residents and/or their relatives spoken with during the visit stated that both the registered provider and the registered manager were approachable and would have no hesitation to talk with one of them should they need to. Questionnaires received from a relative and three GP practices included positive comments with regard to the management of the home. These included: “I have considerable respect for the management”. “This home is very well run with a lot of care for the residents”. “Well managed home I have no concerns”. Care workers spoken with felt supported by the management team and all spoken with stated that there was always someone available to talk to should they need to discuss any issue or concern. Supervision is provided to all care workers working at the home. The registered manager explained that she had obtained a new supervision package from ‘skills for care’ and it was her intention to provided six supervision sessions each year and an annual appraisal for each care worker. Each session will cover a relevant topic to look at and discuss, including basic personal care, listening skills, confidentiality, how to respond to dementia and confusion and recording skills. A new quality assurance and monitoring system has been obtained since the last inspection and the registered provider and registered manager are in the process of completing this. The registered manager explained that working through the paperwork enables her to look at all aspects of daily life in the home and if it is found that something isn’t working so well actions are taking to improve the process. The inspector was informed that staff meetings take place and this was confirmed on speaking with three care workers though minutes of these meetings weren’t available on the day of the visit. The registered provider explained that no money is kept on behalf of the residents. If residents wish to purchase anything the registered provider will pay and then invoice them or their relative at the end of the month. This was confirmed on speaking with a relative visiting on the day of the inspection visit who stated, “Anything she needs they get and put it on the bill”. Aberry House DS0000006356.V339986.R01.S.doc Version 5.2 Page 24 Training in health and safety and COSHH (Control of Substances Hazardous to Health) have been provided and a number of other courses including, fire safety, moving and handling, food hygiene and first aid have been provided to ensure care workers are appropriately trained. Training in infection control is currently being completed. Aberry House DS0000006356.V339986.R01.S.doc Version 5.2 Page 25 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 X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 3 3 X X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 3 X 2 Aberry House DS0000006356.V339986.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 13(4)(C) Requirement The registered person shall ensure that: Unnecessary risks to the health or safety of service users are identified and so far as possible eliminated. The registered person must ensure that the risk assessment documentation is up to date and accurate and that it contains all the risks presented to both the resident and the staff. Care workers need to be aware of all the current risks to the residents and the actions to take to minimise those risks. The registered person shall: Keep the service users plan under review. The registered person must ensure that the residents care plans are kept up to date and accurate. Timescale for action 02/07/07 2 OP7 15(2)(b) 02/07/07 Aberry House DS0000006356.V339986.R01.S.doc Version 5.2 Page 27 3 OP18 13(6) Care workers need to have up to date information to enable them to care properly for the residents. The registered person shall make 02/07/07 arrangements by training staff or by other measures to prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse. 1. The registered person must ensure that any suspected acts of abuse are referred under the safeguarding adults protocol. 2. The registered person must ensure that all staff are aware of the actions to take should any act of abuse be suspected. The residents need to be protected from any possible acts of abuse. The registered person shall give notice to the Commission without delay of the occurrence of – Any event in the care home, which adversely affects the well being or safety of any service user. The CSCI must be informed of any issues that affect the safety of the residents. The registered person shall not employ a person to work at the care home unless-he has obtained in respect of that person the information and documents specified in Schedule 2. 1.The registered person must obtain an up to date CRB on recruitment of all care workers. 4 OP18 37(1) (e) 21/06/07 5 OP29 19 (1) (b) 21/06/07 Aberry House DS0000006356.V339986.R01.S.doc Version 5.2 Page 28 2. The registered person must ensure that appropriate references are obtained. Residents need to be protected by the recruitment procedures that are in place. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Aberry House DS0000006356.V339986.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Aberry House DS0000006356.V339986.R01.S.doc Version 5.2 Page 30 - 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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