Inspection on 22/04/08 for Aberry House

This inspection was carried out on 22nd April 2008.

CSCI found this care home to be providing an Poor service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Aberry House 04/12/07

Aberry House 20/06/07

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 LE2 8PN Lead Inspector Diane Butler Unannounced Inspection 22nd April 2008 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 Aberry House DS0000006356.V362866.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.V362866.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Aberry House Address 6 Monsell Drive Leicester 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 margaret@magnumcare.com Mrs Margaret Madden Mrs Debra Ann Robinson Care Home 38 Category(ies) of Dementia - over 65 years of age (38), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (38), Old age, not falling within any other category (38), Physical disability over 65 years of age (38), Sensory Impairment over 65 years of age (38) Aberry House DS0000006356.V362866.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered provider may provide the following category of service only:Care home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP Dementia - Code DE(E) Mential Disorder, excluding learning disability or dementia - Code MD(E) Physical Disability - Code PD(E) Sensory Impairment - Code SI(E) The maximum number of service users who can be accommodated is 38. 20th June 2007 2. 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 older people some of who have mental health needs and/or dementia. 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 two dining rooms 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 private charges range from £450.00 per week to £550.00 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 (a document which provides relevant information about the home), which is given to all prospective and current residents. Aberry House DS0000006356.V362866.R01.S.doc Version 5.2 Page 5 A copy of the latest Inspection report is available at the home, or it can be accessed via the CSCI website: www.csci.org.uk. Further information about the home is available from the acting manager. Aberry House DS0000006356.V362866.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. This means the people who use the service experience poor outcomes. This was an unannounced visit, which took place over a seven and a half hour period in April 2008. The acting manager was on duty at the time of the inspection. When undertaking key inspections the Commission for Social Care Inspection (CSCI) focuses upon outcomes for residents and their views of the service provided. The primary method of inspection used was ‘case tracking’ which involved selecting four residents and tracking the care they received through looking at their records, speaking with them and their relatives when possible and discussion with staff on duty at the time of the visit. Where communication was difficult observation was used to evidence whether care needs were being met. A further five residents and one relative were also spoken with during the site visit. Comments received during the visit include: “Its well organised”. “The staff are very kind”. “Somebody comes and gives us exercise, that gets us going and livens people up”. What the service does well: The acting manager visits prospective residents before they move into the home and an initial assessment is completed to ensure that their needs can be met. Resident’s privacy and dignity is maintained and residents and relatives spoken with confirmed that their current care and support needs are being met. The home is well maintained and the decoration and furnishings are of a good standard and are presented in a comfortable and homely way. Aberry House DS0000006356.V362866.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: Ensure that a care plan is in place for each resident living in the home. Care workers need to know the tasks they are to carry out in order to meet the resident’s needs. Ensure that all medication and medication records are appropriately maintained, up to date and accurate. Residents need to be protected by robust procedures within medication management. Ensure that all residents have a copy of their Terms and Conditions of residency. This will provide them with relevant information including the charges they have agreed to pay and what the charges cover. Aberry House DS0000006356.V362866.R01.S.doc Version 5.2 Page 8 Review the quality assurance system that is in place. This will enable the acting manager to gather information and current views of the service being delivered. 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.V362866.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.V362866.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): 1,2,3,5,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents needs are assessed prior to them moving into the home. EVIDENCE: A Service User Guide is in place. A copy of this is displayed in the entrance hall of the home and a copy is available to all prospective residents along with a pictorial brochure. Information included in these documents includes the facilities that are available in the home and the help and support that the staff can provide. All prospective residents and/or their relatives are invited to look around the home before moving in to see what the home has to offer. Residents and relatives spoken with during the visit confirmed that they had had the opportunity to look around the home and had received relevant information before moving in. Aberry House DS0000006356.V362866.R01.S.doc Version 5.2 Page 11 The acting manager stated that all new residents receive a terms and conditions of residency which informs them of the fees they will be charged and what is included in that fee. One relative spoken with stated that they had yet to receive this document. The acting manager explained that she was in the process of updating the terms and conditions for all the existing residents to ensure that all have a terms and conditions of residency and it is hoped that these will be sent out in the near future. An initial assessment is carried out for all new residents prior to them coming into the home. If a resident is social service funded a copy of the assessment carried out by their social worker is also obtained. All files checked on this occasion included an initial assessment carried out by the acting manager and those funded by social services also included a copy of their assessment. It was noted that not all assessments had been dated or signed by the person completing them. Comments received during the visit included: “She [the acting manager] came to see me and talk to me about the home”. “I came and looked around and the owner came to see mum at home”. Intermediate care is not currently provided at Aberry House. Aberry House DS0000006356.V362866.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 poor. This judgement has been made using available evidence including a visit to this service. Residents health and personal care needs are currently being met however, lack of care plan documentation could result in care and support needs not being identified and ultimately not being met. Poor recording within medication management could potentially put residents at risk. EVIDENCE: Paperwork belonging to four residents, all of whom have moved into the home since the last inspection in December 2007, was checked during this visit. Only three had care plans in place with the file belonging to a resident who moved into the home in February this year only including an initial needs assessment. The acting manager could not explain why there was no care plan in place but stated one would be developed before the end of the day. Aberry House DS0000006356.V362866.R01.S.doc Version 5.2 Page 13 The acting manager is in the process of reviewing all the care plans and those seen on this occasion were more thorough than on previous visits and in the main included the actions to be taken by the staff to meet the resident’s needs. (It was noted that one of the plans checked didn’t include all of the tasks the carers are required to carry out to meet the residents needs as identified in the assessment carried out by the residents social worker, this included assisting the resident to shave. It was also noted that part of the care plan included the wrong name). The acting manager stated that this would be addressed. Care workers are now responsible for reviewing the care plans on a monthly basis and recording any changes in the residents care. The acting manager then checks at the end of each month that all the plans have been reviewed. On checking daily records it was evident that health care services including GP’s, community nurses and chiropodists are accessed on the residents behalf. Risk assessments were also in place in the four files checked. These covered the risks presented to the individual resident and the actions to be carried out by the care workers to minimise those risks. A notification received by CSCI identified that a resident had developed a grade 4 pressure sore. The acting manager acknowledged that the pressure sore should have been identified much sooner than it was and has taken steps to ensure that this doesn’t happen again. This includes sending herself and two senior carers on a tissue viability training course and arranging with the community nurse to deliver training in pressure area care to the care staff. Pressure area relief equipment was also purchased. Medication records were checked and a number of errors in the recording of medication were evident. These included: • • A tablet being signed as given, though on checking the blister pack where it is stored the tablet had not been given. For one resident it was noted on the MAR (medication administration Record) chart that one tablet had been stopped and a new tablet had been prescribed, the tablet that had been stopped had been discontinued on the MAR chart but the new tablet had not been entered and so staff had been administering this tablet for over eight days without it been signed into the home, entered onto the medication record sheet or signed for when given. On checking the controlled drugs register it was noted that for one resident it was recorded that there were 20 temazepam tablets, on counting the stock it was noted that there were in fact 23 tablets in place. On closer DS0000006356.V362866.R01.S.doc Version 5.2 Page 14 • Aberry House inspection it was noted that on the 19/04/08 the stock balance was recorded as 25, after giving the resident 1 tablet the senior care worker recorded that there were 20 tablets left, not 24, this was witnessed by another member of staff. It was also noted that this was not picked up by the staff member giving the tablet the following night as they had recorded that the remaining balance was 19, not 23. This questions whether staff are actually counting the medication each time it is being given as required. • A relative spoken with explained that on the Sunday prior to the inspection visit, they had found a large white tablet in their mothers room which didn’t belong to her, this was given to the senior in charge, but no explanation was given. This was discussed with the acting manager who stated that this would be looked into. A number of the blister packs were also out of sync with each other with some being started at the beginning of the month, some in the middle of the month and some in the middle of a week. It is strongly recommended that this be looked into. Interaction between residents, care workers and relatives was positive on the day of the visit with staff members speaking to residents and relatives in a respectful, friendly and supportive manner. All residents and relatives spoken with stated that current care needs were being met. Comments received included: “Mum looks well cared for”. “I am satisfied with the care my wife is receiving”. “I am very dependent on others and they are very helpful”. “You’d be alright if you took ill, they would look after you”. Aberry House DS0000006356.V362866.R01.S.doc Version 5.2 Page 15 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 good. This judgement has been made using available evidence including a visit to this service. Residents are encouraged to make choices on a daily basis. EVIDENCE: Residents spoken with confirmed that they were able to make choices on a daily basis. These include when to get up and go to bed, what to have at mealtimes and whether to join in activities offered. An activities leader is employed to provide regular activties for the residents living in the home, however, this staff member is currently covering a senior position at Aberry House’s sister home Alston House and therefore not available as regularly as the registered provider would like. Care workers currently provide activity sessions morning and afternoon and the activities leader visits the home on a Tuesday and Thursday afternoons to provide gentle exercise and aromatherapy sessions. Aberry House DS0000006356.V362866.R01.S.doc Version 5.2 Page 16 A comment included in a relative survey received prior to this visit did infer that residents would benefit from further activities being offered. The survey stated: “It’s the quality of life, activities etc that are lacking”. Visiting is strongly encouraged and all relatives spoken with stated that they were made welcome and can visit at any time. Specific religious and cultural needs are met. Communion is offered on a regular basis and one resident is enabled to attend the local polish centre on a weekly basis. A nun from the local Catholic Church provided communion for three residents during the visit. Residents and relatives spoken with during the visit stated that the food served in the home was generally good, and choices are always offered. During the visit one of the care workers was seen finding out residents preferences for lunch and tea that day. The acting manager explained that a recent change to the breakfast time which is now provided between 7.30am and 9.45am enabled the residents to get up later if they wanted. Comments received included: “You can get up when you want to, I generally wake and get to breakfast for about 8.00am”. “The foods quite good”. “The meals arent bad at all, the portions are quite adequate, you don’t want a lot, too much puts you off”. “The quality is there, it is sometimes a little cold but its nice”. Comments included in a resident survey received prior to the visit stated that: “The meat is tough and there is hardly any fresh fruit”. “Small plates are used with little food for main course, but generous puddings which are both fattening and filling”. The meal served during the visit looked appealing, with a choice of quiche or beef stew and dumplings with vegetables and croquet potatoes being offered. Aberry House DS0000006356.V362866.R01.S.doc Version 5.2 Page 17 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 good. This judgement has been made using available evidence including a visit to this service. Residents and their relatives are confident that their complaints will be listened to and acted upon. EVIDENCE: A complaints procedure is in place. A copy of this is displayed in the entrance hall and all residents and/or relatives spoken with were aware of who to talk to if they werent happy about something. Comments received included: “There are one or two staff who I would ask to pass any concern on”. “I would speak to the one in charge”. “I would talk to any of the staff, they’d sort it out”. “I would talk to xxx [acting manager] Aberry House DS0000006356.V362866.R01.S.doc Version 5.2 Page 18 The acting manager stated that no written complaints have been received since the last inspection in December 2007 and this was confirmed on checking the complaints file. Two verbal complaints have been received regarding a residents laundry and a resident not getting a drink of apple juice and these were looked into and addressed by the acting manager. All care workers spoken with were aware of the actions to take should they suspect an act of abuse and residents and/or their relatives spoken with during the visit stated that they felt safe living at the home. Protection of Vulnerable Adults training has been arranged with Leicester College and this is due to be delivered in the next six months. Aberry House DS0000006356.V362866.R01.S.doc Version 5.2 Page 19 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): 19,20,21,23,24,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of the accommodation within the home is good, providing residents with a pleasant and homely place to live. EVIDENCE: The areas of the home seen on this occasion were well maintained and suited to the residents needs. Decoration is of a good standard and furnishings in the communal areas are domestic in character and in good condition. There are thirty six single bedrooms and one shared bedroom with all but one of these rooms offer ensuite facilities. The room without ensuite facilities has a toilet close by. Aberry House DS0000006356.V362866.R01.S.doc Version 5.2 Page 20 Work has recently been carried out to improve access into the main dining room at the front of the home and an archway has been created in the main corridor, which enables easier access for wheelchair users. The room belonging to one of the resident’s spoken with was seen. This was clean, furnished the way they preferred and included their own personal belongings. Assisted bathing facilities are available and a new shower room is provided on the first floor. There is an attractive secure garden area to the rear of the home. This is accessible to all residents, with ramps and handrails in place to assist those who are less mobile. Aberry House DS0000006356.V362866.R01.S.doc Version 5.2 Page 21 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 good. This judgement has been made using available evidence including a visit to this service. Residents are supported and protected by the homes recruitment practices. 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. The acting manager has developed a new recruitment and selection policy and procedure to ensure new staff are recruited correctly. Three staff files were checked and were found to include the relevant checks including a POVA (Protection Of Vulnerable Adults) 1st check, CRB Criminal Records Bureau) check and references, though it was noted that one care worker had two character references and one only had one character reference in place. The acting manager stated that the second reference would be chased up. Aberry House DS0000006356.V362866.R01.S.doc Version 5.2 Page 22 The acting manager stated that both induction training and supervision is offered to all staff working at the home. This was confirmed on checking the staff files and during discussion with care workers on duty on the day of the inspection visit. Staff have been provided with fire safety awareness training, dementia awareness training and stoma care training since the last inspection in December 2007 and the acting manager has also sourced a number of courses through Leicester college which will be provided in the next six months. These include: Protection of Vulnerable Adults training. Medication training. Challenging Behaviour training. First aid training. The acting manager and two senior care workers have completed tissue viability training and the acting manager is a moving and handling trainer and provides moving and handling training to new staff, prior to an external course being completed. Eight care workers have commenced their NVQ (National Vocational Qualification) level 2 and seven care workers have commenced their NVQ level 3. Aberry House DS0000006356.V362866.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,37,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Not all records required by regulation for the protection of the residents are up to date or accurate. Resident’s financial interests are safeguarded. EVIDENCE: An acting manager is currently running the home due to the long term sickness of the current registered manager. The acting manager has completed her NVQ level 4 and Registered Managers Award. Aberry House DS0000006356.V362866.R01.S.doc Version 5.2 Page 24 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. Money kept on behalf of three residents was checked. All three were in order with the appropriate signatures and records kept. Money is stored in individual wallets and only the acting manager has access to this. Daily records were checked, a report is written after each shift and details of visits by GPs, community nurses etc are kept. Not all records checked on this occasion were up to date and fully completed, this includes medication records, assessment documentation and care plans. Accident records seen on this occasion corresponded with the resident’s daily records and the acting manager carries out a monthly audit on falls to identify any patterns and whether changes in daily living are required. The acting manager stated that staff meetings are held and this was confirmed on speaking with staff on duty during the visit and on checking minutes taken at the last meeting held on 26th March 2008. An open afternoon is arranged for the residents and their relatives on 1st June. The acting manager explained that she wanted to give everyone an opportunity to get together and meet and chat with herself and the staff. Required checks are completed in relation to hot water temperatures and fire alarms are tested on a regular basis. A new fire risk assessment has been produced and training in fire awareness has been provided since the last inspection visit in December 2007. COSHH (Care of Substances Hazardous to Health) training is booked for 26th May and a one day first aid course has been booked with Leicester College. A quality assurance and monitoring system is in place, however this has not been reviewed of late due to the registered managers long term absence. Aberry House DS0000006356.V362866.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 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 X 3 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X 2 3 Aberry House DS0000006356.V362866.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No 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 15 (1) Timescale for action The registered person shall, after 02/05/08 consultation with the service users, or a representative of his, prepare a written plan as to how the service users needs in respect of his health and welfare are to be met. The registered person must ensure that an up to date and accurate care plan is in place for each resident living at the home. Care staff need accurate information in order for them to meet the needs of the residents in their care. The registered person shall make 02/05/08 arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. The registered person must ensure that all medication received into the home is appropriately recorded and medication records are up to date and accurate. Aberry House DS0000006356.V362866.R01.S.doc Version 5.2 Page 27 Requirement 2 OP9 13 (2) Residents need to be protected by accurate medication management and record keeping. 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 3 Refer to Standard OP2 OP9 OP33 Good Practice Recommendations The registered person should ensure that all residents receive a copy of their Terms and Conditions of residency. The registered person should contact the pharmacist in order to streamline the current blister pack system. The registered person should review the quality assurance system that is in place. Aberry House DS0000006356.V362866.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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.V362866.R01.S.doc Version 5.2 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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