Inspection on 09/05/06 for Abiden Rest Home

This inspection was carried out on 9th May 2006.

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

Abiden Rest Home 21/05/08

Abiden Rest Home 04/07/07

Abiden Rest Home 29/11/05

Abiden Rest Home 08/06/05

Abiden Rest Home 28/04/04

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

CARE HOMES FOR OLDER PEOPLE Abiden Rest Home 22/24 Rosehill Road Burnley Lancashire BB11 2JT Lead Inspector Mrs Julie Playfer Unannounced Inspection 9th May 2006 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 Abiden Rest Home DS0000009469.V287877.R01.S.doc Version 5.1 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. Abiden Rest Home DS0000009469.V287877.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Abiden Rest Home Address 22/24 Rosehill Road Burnley Lancashire BB11 2JT 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) 01282 428603 Mr John Alexander Pinder Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (22) of places Abiden Rest Home DS0000009469.V287877.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th November 2005 Brief Description of the Service: Abiden is registered with the Commission for Social Care Inspection to provide accommodation and personal care for 22 Older People. The home is well maintained and situated within easy access of the town centre. The gardens are attractive and have patio areas, which are readily accessed by the residents. Accommodation comprises of 18 single rooms, 8 of which are ensuite and 2 double rooms both ensuite. There is a chair lift to the first floor. Communal space is provided in 3 lounges, 2 of which have a television and the other is used as a quiet room. The home also has two assisted baths and one shower room. At the time of the inspection the scale of charges ranged from £315.00 to £350.00. Additional charges were made for personal newspapers/magazines, personal telephone and incontinence pads. The registered provider made information available to prospective residents by means of a statement of purpose and service users guide. This document was usually given to relatives and/or prospective residents on viewing the home or at the point of assessment. Abiden Rest Home DS0000009469.V287877.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced and took place over eight hours on 9th May 2006. The previous statutory inspection was carried out on 29th November 2005. There have been no additional visits made to the home since the last inspection. On the day of inspection there were 22 residents accommodated in the home. Information was obtained from staff records, care records and policies and procedures. The inspector undertook a partial tour of the premises and spoke to the residents, the staff on duty and the registered person. Three residents were involved in the case tracking process. Prior to the inspection the registered person completed a questionnaire, which provided useful information for the inspection. Comment cards had been sent to the home for residents and their relatives, 12 cards were returned from residents and 5 cards were received from relatives/visitors to the home. What the service does well: Prospective residents were encouraged and supported to visit the home prior to admission. This provided the opportunity to meet the other residents, have a look round the home and sample the meals. The daily routines were flexible and designed to meet the wishes of the residents, many of the residents chose to have a “lie in” the morning and breakfast was served in their bedroom, if they wished. Activities were arranged in line with the needs and preferences of the residents, which included regular trips out in the local area. The home provided varied and well-presented meals. All residents spoken to described the meals as “very good”. Visitors were welcome in the home at any time and residents were supported to maintain good contact with their family and friends. The residents had access to a complaints procedure, which contained clear information about how to make a complaint. Residents were provided with clean and nicely decorated bedrooms that were well-maintained. The residents could personalise their rooms with their own ornaments and small items of furniture. The sitting and dining areas were decorated in a homely and comfortable fashion, with a variety of armchairs, footstools, side tables, ornaments and wall pictures. Abiden Rest Home DS0000009469.V287877.R01.S.doc Version 5.1 Page 6 Residents spoken to felt they received a good standard of care and the staff respected their rights to privacy and dignity. One resident said, “I have nothing but good to say about this home” and another person commented, “ I think the staff are wonderful”. The overall atmosphere in the home was open and friendly. What has improved since the last inspection? What they could do better: Abiden Rest Home DS0000009469.V287877.R01.S.doc Version 5.1 Page 7 Written information provided for residents including the service users guide and the contract must be updated to ensure residents receive clear information about the services and facilities and the amount and payment of fees. All residents must have a plan of care, which details their needs and includes guidance to staff on how to meet these needs. The plan should be generated from the assessment of needs on admission, so staff are aware of how to support and care for the person. Improvements must be made to the management of medication to safeguard the health and welfare of the residents. The registered person must ensure there are sufficient staff on duty at all times in order to meet the needs of the residents. A meaningful quality assurance system must be developed to monitor the service and provide evidence that the home is run in the best interests of 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. Abiden Rest Home DS0000009469.V287877.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Abiden Rest Home DS0000009469.V287877.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 and 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The residents were provided with useful information and were encouraged to experience life in the home prior to admission. However, the residents had not received sufficient information about the amount and payment of fees. EVIDENCE: Since the last inspection, the service users guide and statement of purpose provided to residents had been updated to include the correct registration criteria and details about room sizes. The guide and statement of purpose had been amalgamated into one document and had been issued to all residents. The document provided useful information the services and facilities provided in the home. One resident told the inspector she had read the service users guide and had “found out a lot about the home”. However, it was noted that whilst the service users guide suggested useful questions prospective residents may want to ask before they moved into the home, there were no answers to the questions written into the guide. Abiden Rest Home DS0000009469.V287877.R01.S.doc Version 5.1 Page 10 From the three case files seen it was evident that two residents had been issued a contract and one resident had not. Of the two contracts issued only one contract contained details about the level of fees, although both had been signed. One resident had been admitted to the home since the last inspection. It was apparent that the staff had carried out a preadmission assessment of needs, which covered the person’s health, social and personal needs. Following the assessment the registered person had confirmed in writing to the resident that the home was suitable for meeting her needs. Prospective residents were actively encouraged to spend some time in the home prior to making the decision to move in. One resident remembered her first to the home and told the inspector she knew as soon as she “walked in, it was the place for me, as everywhere was very clean and everyone was friendly”. Abiden does not provide intermediate care. Abiden Rest Home DS0000009469.V287877.R01.S.doc Version 5.1 Page 11 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 and 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. Not all residents had a plan of care and the systems in place to manage medication had the potential to place residents at risk. EVIDENCE: It was apparent from the case tracking process that two of the three residents had a care plan. Since the last inspection the care planning system had been developed and expanded to include greater detail about the residents’ needs. The care plans had been reviewed on a monthly basis; however, one person’s plan had not been reviewed since February. Whilst the residents had signed the care plan to indicate their participation in the review process, none of the residents spoken to could recall discussing their care needs with a member of staff. Risk assessments had been incorporated into the care plan documentation, which included risk management strategies to manage, reduce or eliminate an identified hazard. The care plans were supported by records of personal care, which provided information on changing needs and any recurring difficulties. Since the last inspection the care records had been maintained on a separate and individual Abiden Rest Home DS0000009469.V287877.R01.S.doc Version 5.1 Page 12 basis. All records seen were detailed and the residents’ needs had been described in respectful terms. With the exception of one the residents’ healthcare needs were included within the care plan and information was available on specific medical conditions. Charts were maintained to record baths and other aspects of personal care. However, the weight chart had not been maintained for one resident involved in the case tracking process. Risk assessments had been carried out in respect of falls and nutrition. Psychological health was monitored and one resident said the staff often spent time talking to her about some personal difficulties. The residents spoken to felt the staff respected their right to privacy and all made complimentary remarks about the staff, for instance one resident said the staff were “wonderful and will do anything for you”. The staff were observed to interact with the residents in a positive manner and they referred to the residents in their preferred term of address. The home operated a monitored dosage system for the administration of medication, which was dispensed into cassette trays by a local pharmacist. The policies and procedures relating to medication had been reviewed and revised since the last inspection; however, there was no procedure for the disposal of medication. An appropriate recording system was in place to record the receipt, administration and disposal of medication. However, there were shortfalls noted in the overall management of medication. These included shortfalls in the record keeping, the administration of medication and the storage of medication. At the time of the inspection the staff were undertaking an accredited training course. Abiden Rest Home DS0000009469.V287877.R01.S.doc Version 5.1 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, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents were able to choose their life style, social activity and kept in contact with their friends and family. Residents received a healthy and varied diet according to their assessed requirement and choice. EVIDENCE: The residents’ preferences in respect of social activities had been recorded as part of the assessment. The residents were encouraged to pursue a range of activities both inside and outside the home. Activities inside the home included professional entertainment, film matinees, sing-a-longs, parties and board games. Residents were also involved in activities outside the home and these included going to local pubs and restaurants, shopping, lunch and coffee mornings at the local Baptist church and visits to historical sites. The residents spoken to said they had enjoyed a trip to Towneley Park, the day before the inspection and a recent trip to a local pub for lunch. The residents had varied views about the activities provided, of the 12 residents who returned a comment card 8 people said they thought the home provided suitable activities, 2 people responded sometimes and 2 people felt the home did not provide suitable activities. Abiden Rest Home DS0000009469.V287877.R01.S.doc Version 5.1 Page 14 The routines in the home were well established and residents had a choice in the times they went to bed and got up in the morning. One resident said “I please myself when I go to bed and I get up when I want to”. Hence breakfast was served throughout the morning to suit the wishes of the residents. The staff were observed to seek the views of residents throughout the inspection and residents said they felt comfortable to comment on life in the home. The home operated a key worker system, which also facilitated closer resident staff relationships where likes, dislikes and needs were shared. There were no restrictions placed on visiting and residents were able to entertain their guests in the privacy of their bedrooms. All the relatives and visitors who returned comment cards said that they felt welcome in the home and all were satisfied with the level of care provided. Residents spoken to described the meals as “very nice” and “lovely”. They also said there was always plenty to eat and the food was a good quality. The registered person explained that there was a choice of food at every mealtime and residents were asked at lunchtime when the meal was served what choice they wished to make. A range of different drinks was served with the lunchtime meal on the day of inspection including various alcoholic beverages, fruit juices and tea and coffee. The meal looked appetising and was well presented. Drinks and snacks were served at set times throughout the day and other times on request. Residents were observed asking for drinks during the inspection and were promptly served by the staff. The menu was displayed in the dining room and residents were aware of the forthcoming meal. Abiden Rest Home DS0000009469.V287877.R01.S.doc Version 5.1 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 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents had access to a clear up to date complaints procedure and staff had access and an awareness of the adult protection procedure. EVIDENCE: The complaints procedure was incorporated in the statement of purpose/ service users guide. The procedure contained the necessary information should a resident wish to raise a concern and included the address and contact number of the Commission. The residents said they could talk to any of the staff in the event they had a complaint or wished to raise a concern. The registered person had received one complaint in the last 12 months, which had been sent direct to the Commission. The registered person investigated the complaint and a record of the investigation and outcome had been maintained in the home. Since the last inspection, the registered person had updated and revised the adult protection procedure. This procedure set out the required response in the event of an allegation, suspicion or evidence of abuse and complemented the local procedures outlined in “No Secrets in Lancashire”. Some staff had received training on the protection of vulnerable adults and when interviewed demonstrated an awareness of the procedure. All staff had access to a whistle blowing procedure. Abiden Rest Home DS0000009469.V287877.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The residents were provided with a clean, comfortable and well- maintained environment. EVIDENCE: Abiden is a mature property with its own garden. The home is located within easy access of the town centre. Accommodation is provided in 18 single rooms, 8 of which have an ensuite and 2 double rooms both of which have an ensuite. The home also provides two assisted baths and one shower room. Communal space is provided in three lounges and one dining room. Since the last inspection, new non-slip flooring had been fitted in the corridor, kitchen and toilets. A new oven had also been purchased for the kitchen. The residents had access to well-maintained gardens, which included several seating areas. It was evident from a partial tour of the home that residents had personalised their rooms with their own belongings and decoration was good throughout. Abiden Rest Home DS0000009469.V287877.R01.S.doc Version 5.1 Page 17 The residents said their rooms were comfortable and warm. One resident said her room was “absolutely lovely” and she enjoyed sitting in it every evening watching television. Residents had been provided with aids and adaptations to assist their independence skills, these included grab rails, handrails, raised toilets and ramps for wheelchairs. Since the last inspection a new chair lift had been installed to access the main stairs to the first floor accommodation. The provision of specialist equipment was determined by the needs of the residents. There was a call facility in every room. The doors to residents’ bedrooms had been fitted with appropriate locks and residents were observed to be using keys. Exposed pipe work and radiators had been fitted with appropriate guards, with the exception of two radiators in the lounges. The unguarded radiators had been protected by furniture and a risk assessment had been carried out in respect to the risks to residents. The registered person reported there was a central valve fitted to the water system to control water temperature within the home. Since the last inspection a preset valve had been fitted to the baths in order to guarantee the water temperature and an ongoing record of the water temperature had been maintained. The standard of cleanliness was good in all areas seen. All residents spoken to said the home was clean and tidy. Abiden Rest Home DS0000009469.V287877.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Staff in the home were trained and skilled, however, on occasions there were insufficient care staff on duty. EVIDENCE: The registered person maintained a staff roster, which was completed in advance. From inspection of the roster it was noted that there were occasions when the home was operating with below minimum number of staff carrying out care duties. The files of three members of staff, who had commenced work in the home since the last inspection, were examined. Whilst a recruitment and selection procedure was not seen, it was noted that both staff had completed an application form, provided a full working history and attended a face-to-face interview. Two written references and police checks had been sought and received prior to the staff commencing work in the home. Arrangements were in place to ensure staff received appropriate induction training and other training such as moving and handling in line with the needs of the residents. Information contained in the pre inspection questionnaire indicated that 8 members of staff had completed NVQ level 2 or above, this equated to 51 of the care staff were qualified. Abiden Rest Home DS0000009469.V287877.R01.S.doc Version 5.1 Page 19 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, 32, 33, 35, 36, 37 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Arrangements had been established to formally consult both residents and staff, however, the quality assurance systems required development to fully monitor the service received by the residents. Suitable arrangements were in place to maintain the health and safety of residents. EVIDENCE: The registered person had the overall responsibility for the management of the home and had completed an NVQ level 4 in Management and the Registered Manager’s Award, Mr Pinder had also undertaken periodic training to update his knowledge and skills. Relationships within the home were good and staff spoke about the residents with respect. The residents valued the help and support they received from the Abiden Rest Home DS0000009469.V287877.R01.S.doc Version 5.1 Page 20 staff, who they described as “very patient ” and “friendly”. One resident said, “it’s good to talk and have a joke with the staff”. Since the last inspection a programme of staff supervision had been established, however, it was noted from the records that not all elements listed in the National Minimum Standards had been covered. Since the last inspection, one residents’ meeting had been arranged. The residents spoken to welcomed this initiative and one person said the meeting was a useful means of “sorting a few things out”. The meeting was presented as a social occasion and residents were encouraged to voice their views about life in the home. There had also been one staff meeting and three management meetings arranged since the previous visit to the home. The home achieved a post recognition Investor’s in People award in 2004. Some progress had been made to monitor the quality of the service. Several residents had completed satisfaction questionnaires and similarly the views of relatives had been sought by means of a questionnaire. However, the registered person had not completed all the surveys at the time of the inspection and the results had therefore not been collated. A means to monitor the systems in the home and evidence of an internal audit were not seen during the inspection. Further to this the registered person confirmed that an annual development plan based on the findings of the quality assurance systems had not been devised. At the time of the inspection, the registered person was not managing the money for any resident. Records were maintained of money received in payment of fees and any additional charges. Not all records had been collated and maintained in accordance with the Care Homes Regulations 2001, for instance records relating to the management of medication. The registered person had also not informed the Commission of events in the home detailed under Regulation 37. There was a set of health and safety procedures available, which included the safe storage of hazardous substances. Staff received yearly health and safety training, which included moving and handling, food hygiene, first aid and fire safety. Staff had also completed an infection control training course. Documentation was seen during the inspection which, confirmed gas and electrical systems were serviced at regular intervals. The electrical safety certificate was dated 2003 and was valid for 5 years. The fire log demonstrated that staff had received instructions about the fire system and fire alarms were tested weekly. Abiden Rest Home DS0000009469.V287877.R01.S.doc Version 5.1 Page 21 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 2 2 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 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 3 3 3 3 3 STAFFING Standard No Score 27 1 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 2 2 3 Abiden Rest Home DS0000009469.V287877.R01.S.doc Version 5.1 Page 22 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 OP2 Regulation 5 (1) (b) Requirement The amount and payment of fees must be included in the terms and conditions of residence/contract. All residents must have a care plan, based on their assessment of needs. (Previous timescale of 31/12/05 – not met). All care plans must be reviewed once a month. All residents must have a care plan, which details their healthcare needs. This must be generated from the assessment of needs following admission. All medication must be administered in line with the prescribers instructions. All changes in medication must be clearly recorded in the daily records of care and the medication administration record. Who made the change and the reasons why the change has been made must also be recorded. Prescribed medicines stored in the trolley must be clearly marked with a prescription label. DS0000009469.V287877.R01.S.doc Timescale for action 15/06/06 2. OP7 15 (1) 09/05/06 3. 4. OP7 OP8 15 (2) (b) 15 (1) 09/05/06 09/05/06 5. 6. OP9 OP9 13 (2) 13 (2) 09/05/06 09/05/06 7. OP9 13 (2) 09/05/06 Abiden Rest Home Version 5.1 Page 23 8. 9. 10. OP9 OP9 OP27 13 (2) 13 (2) 18 (1) (a) 11. OP33 24 12 OP37 37 Eye preparations must be clearly dated on opening and discarded after 28 days. A risk assessment must be carried out for all those residents who self-administer medication. The registered person must ensure the staffing levels are maintained at all times. Therefore one senior care staff and two care staff must be on duty to carry out care duties throughout the waking day as a minimum. (Previous timescale of 29/11/05 – not met). An annual development plan must be devised based on a systematic cycle of planning, action and review, reflecting the aims reflecting the aims and outcomes for service users. There must also be continuous monitoring, using an objective, consistently obtained and reviewed and verifiable method (preferably a professionally recognised quality assurance system) and involves the service users and an internal audit takes place at least annually. (Previous timescale - 1st September 2005 and 1st March 2006 - not met). The Commission must be notified in writing without delay of all incidents and events listed under Regulation 37. 09/05/06 30/05/06 09/05/06 31/08/06 09/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Abiden Rest Home DS0000009469.V287877.R01.S.doc Version 5.1 Page 24 No. 1. 2. 3. 4. 5. 6. 7. Refer to Standard OP1 OP8 OP9 OP9 OP29 OP33 OP36 Good Practice Recommendations Further information should be included in the service users guide in respect to the list of frequently asked questions. A record of weight should be maintained for each resident on a regular basis. Staff designated to administer medication should complete the accredited medication course. The policies and procedures relating to medication should include a procedure on the disposal of medication. A recruitment and selection procedure should be devised. The results of residents surveys should be collated and made available to residents and their representatives and other interested parties. Staff supervision should cover the topics listed under Standard 36. Abiden Rest Home DS0000009469.V287877.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB 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 Abiden Rest Home DS0000009469.V287877.R01.S.doc Version 5.1 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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