Inspection on 11/04/05 for Amesbury Abbey Nursing Home

This inspection was carried out on 11th April 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Amesbury Abbey Nursing Home 10/02/09

Amesbury Abbey Nursing Home 13/04/07

Amesbury Abbey Nursing Home 18/05/06

Amesbury Abbey Nursing Home 11/10/05

Amesbury Abbey Nursing Home 06/01/05

Amesbury Abbey Nursing Home 21/06/04

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

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

CARE HOMES FOR OLDER PEOPLE Amesbury Abbey Nursing Home Amesbury Wiltshire SP4 7EX Lead Inspector Susie Stratton Unannounced 11 April 2005 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 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. Amesbury Abbey Nursing Home Version 1.10 Page 3 SERVICE INFORMATION Name of service Amesbury Abbey Nursing Home Address Amesbury Wiltshire SP4 7EX Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01980 622957 01980 623767 Mrs Evelyn Mary Cornelius-Reid Mrs Esther Rose Thomas Care Home with Nursing 50 Category(ies) of OP Old Age (50) registration, with number PD Physical Disability (2) of places TI Terminally ill (3) Amesbury Abbey Nursing Home Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: 1. No more than 3 people in receipt of terminal care at any one time. 2. No more than 2 Physically Disabled residents at any one time. 3. No more than 50 service users over 65 years of age at any one time. Date of last inspection 6 January 2005 Brief Description of the Service: Amesbury Abbey provides care with nursing for up to fifty people. However, a number of rooms registered as doubles are often occupied as singles, this reduces occupancy levels to a more usual figure of around forty. Most of the rooms are in the form of apartments with their own bedroom and sitting room as well as a bathroom. The property is a listed building, set in extensive grounds. Accommodation is provided over three floors. The amenities of the small town of Amesbury are close by. Ample parking space is available on site and a bus stop is situated at the end of one of the drives. The home is close to the A303. The closest main line railway is in the city of Salisbury, about 20 minutes away. The home is part of a group of four establishments. The Registered Owner, Mrs M Cornelius-Reid, founded the group. She remains closely involved with all the homes. The registered manager for the home is Mrs Esther Thomas, she is supported by her deputy, Mrs Helen Collins and a team of nursing and care staff. Mr David Cornelius-Reid, site manager, manages the maintenance, housekeeping and administrative staff of the home as well as acting as Mrs Cornelius-Reid’s deputy. Also situated within the grounds are Amesbury Abbey Mews. These provide sheltered accommodation for more able elderly people. From time to time residents of this scheme may move to the Abbey as their needs increase. The Mews is not part of the registered accommodation, and is not directly linked to the Abbey. Amesbury Abbey Nursing Home Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place on a Monday between 9.55am and 4.40pm, it was carried out with the support of Mrs Helen Collins, Deputy Manager. The Inspector also met with Mr David Cornelius-Reid, site manager, the hotel services manager, the training manager, three care assistants, the chef and his assistant, the receptionist, one domestic, two laundresses and one of the maintenance men. A GP and podiatrist were also in the home at the time of the inspection. During the inspection, the Inspector met and spoke with nineteen service users and observed the care of four frail service users who were unable to communicate. The Inspector toured the building, including the kitchen and laundry areas, reviewed documentation and looked at the care records of eight of the service users in detail. What the service does well: What has improved since the last inspection? The nursing and care staff have further developed their care planning system, to reflect individual needs of service users. Care plans are now in place detailing service users needs for activities and recreation and how service users with additional mental health care needs are to be supported. An activities programme has been developed, different activities are now offered most afternoon. Service users said that they were pleased with the activities, one said “I am enjoying them”. An assisted shower room has been completed Amesbury Abbey Nursing Home Version 1.10 Page 6 on the first floor, to support disabled service users, it was reported to be very popular. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Amesbury Abbey Nursing Home Version 1.10 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Amesbury Abbey Nursing Home Version 1.10 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 3 4 5 Service users’ nursing and care needs are fully assessed prior to admission and the home demonstrated that it can meet these care needs. The service users’ guide is not freely available to all, so service users currently living in the Abbey are not made aware of what is offered and the findings of the most recent inspection report. EVIDENCE: Service users have their nursing and care needs assessed by the manager, Mrs Thomas or Mrs Collins prior to admission. After admission, documentation shows that further assessments are made, as staff get to know service users’ needs in more detail. Amesbury Abbey cares for frail elderly persons, some of whom have complex nursing and care needs and a few of whom have dual physical and mental health needs. Staff are able to meet the needs of service users with complex general nursing needs and where service users have mental health care needs, regular reviews take place, involving relevant healthcare professionals. Mrs Collins reported that service users generally come and see round the home, supported by their families prior to admission. Two service users said that they had had lunch and spent the afternoon in the Abbey before deciding Amesbury Abbey Nursing Home Version 1.10 Page 9 on admission. The most recently admitted service users had all been given a copy of the service users’ guide prior to admission, including a copy of the most recent inspection report. However the service users’ guide is not freely available to all, service users have to ask the manager if they want to look at the guide. Systems are needed to ensure that all service users are given access to the guide, which must include the summary of the most recent inspection report. Amesbury Abbey Nursing Home Version 1.10 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7 8 10 Care plans are regularly evaluated and up-dated when service users’ conditions change, so that changed needs can be met. Staff at all levels showed an awareness of the importance of ensuring service users’ dignity and treating them with respect. EVIDENCE: Nursing and care staff have put much effort into developing a care planning system. Service users’ care plans reflect what was observed during the inspection and what was described by service users. Service users with dietary care needs had assessments and care plans to meet these needs, such service users were regularly weighed, to assess the effectiveness of the plan. Service users with bowel care needs had care plans in place and their conditions were regularly monitored, with evidence of interventions, when needed. Service users are assessed for risk of falls. One service user had a very clear care plan which detailed the actions to be taken when they did fall. Care plans for service users with additional mental health care needs have recently been developed, these reflected what was documented in daily records. Mrs Thomas is currently regularly monitoring the needs of two service users. At present they can be managed in the home as their conditions are Amesbury Abbey Nursing Home Version 1.10 Page 11 largely stable. One of these service users did show wandering behaviours during the inspection, but their records indicated that this did not happen on a daily basis and that generally the service user’s condition was more stable. One care plan to reduce risk of pressure damage was not consistent with other plans and did not reflect the service user’s assessed risk. Mrs Collins reported that this related to the individual’s care needs. This was not documented. Service users with wounds had clear plans and monitoring systems in place. All care plans had been evaluated monthly and nearly all had been signed by the service user or their relative. Staff were noted to knock on apartment doors and await a reply, prior to entering. Service users’ records documented their preferred names and staff were observed to call service users by these preferred names. One member of staff was observed to treat a service user with care and delicacy when meeting their complex individual needs. Most accommodation is in the form of apartments and those that are not, are all large enough for a sitting area, so service users are able to meet friends and family in private. Service users can meet their medical practitioners in private if they wish, this took place for one service user who was observed to ask to be on their own with their GP. The laundresses took care to identify service users’ own clothes and ensure that they are always returned to the service user. Where net underwear is used, systems are in place to ensure that items are always returned to the named service user. Amesbury Abbey Nursing Home Version 1.10 Page 12 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 standard(s) 12 13 14 15 Amesbury Abbey have developed programmes to meet service users’ social needs, visitors are encouraged and service users can go out of the home, all this prevents social isolation and improves well-being for older people. The home’s ethos largely supports service users in maintaining control over their lives. EVIDENCE: Amesbury Abbey is in the process of introducing activities programmes. A review of the programme shows that activities are now offered most afternoons. Service users said that they enjoyed the exercise classes and two said that they were looking forward to the gardening group. Several service users said how much they had enjoyed watching the royal wedding in the drawing room together with everyone else who was interested. The care assistant responsible for activities has not yet attended a relevant course to support her in her role. This has been recommended for the past two inspections. All service users’ needs for social contact have now been assessed and plans are being put in place to meet these needs. Service users reported that their friends and family are free to visit whenever they want. Several said that they regularly went out of the home. One service user said that they had attended the local church on Sunday with a family member. Amesbury Abbey Nursing Home Version 1.10 Page 13 Service users reported that it was up to them as to when they got up, went to bed and how they chose to spend their day. Service users who wish to smoke may do so and equipment was available in the home to ensure that other service users were not affected by the cigarette smoke. A system for identifying rooms has not yet been introduced. This has been recommended for the past two inspections, following suggestions made by service users. It was raised again by a service user during this inspection who said that they found it difficult as communal wcs and bathrooms were not labelled and as the doors were all the same, they found it difficult locating such facilities if they were in the dining room or drawing room. Name badges are not used for staff, as has been recommended for the past two inspections. One service user said that name badges would help as the names of younger persons and staff from aboard were different from what they were used to and they found it difficult to remember names and felt guilty for “always asking”. One newly admitted service user was observed asking two different members of staff for their names, explaining that they found it difficult to remember names. The catering manager and chef were keen to provide service users with meals that they liked and would cook meals individually for service users and their relatives if they wished. All meals, including soups, are cooked from raw ingredients. Service users reported that they had a choice at suppertime but no one spoken with in their rooms in the morning could remember what was for lunch. The catering manger agreed to give the catering assistant a copy of the lunch menu so that when she was finding out what service users wanted for supper, she could also remind them of what was for lunch. Meals can be taken in the dining room, the conservatory or in service users’ rooms as they wish. Two service users said that they usually ate in the dining room but that on this day they had decided not to and this was respected. Service users were complimentary about the meals, one said “We’ve very good food here” and another said that the meals were “pretty good”. Amesbury Abbey Nursing Home Version 1.10 Page 14 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 standard(s) 16 The Abbey has a complaints process and this is reported to work in practice. Staff note small but significant matters for service users, to ensure that they are protected from harm. EVIDENCE: Amesbury Abbey has a complaints procedure and service users spoken with were aware of how to bring up issues of concern. One service user said that Mrs Collins “Always sorts things out”, if the carers were not doing things properly. Another said “I’d tell the manager if I wasn’t treated properly.” Where service users or their relatives raise concerns, these are documented. In one record, while the concern was documented, the outcome and actions were not. Care records showed that staff documented any unexplained bruising and investigated the cause. Small but significant details, such as jagged fingernails were noted to be observed by staff and action taken to protect service users. Abuse awareness is part of the home’s standard training for all staff. Mrs Thomas and Mrs Collins have experience of working within the local vulnerable adults procedures. Amesbury Abbey Nursing Home Version 1.10 Page 15 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 standard(s) 19 20 21 22 23 24 25 26 Due to its size, the home is complex to maintain, a range of maintenance matters need to be addressed. Most areas relating to hygiene are in place, however in the absence of appropriate equipment, the home is unable to ensure the proper cleansing of sanitary items. EVIDENCE: Maintenance issues have been identified at several previous inspections, most items have been addressed but now other areas have been identified at this inspection. There does not appear to be a consistent approach towards planned maintenance, in this complex building. Some carpets have been replaced since the previous inspection, unfortunately the colour match is not quite the same as the present carpets. Other carpets in communal areas continue to be stained and not secure, with bubbles visible [see also under standard 38]. The owners were required at the previous inspection to replace all worn and deteriorated carpets by 30th September 2005. In addition to the above, other items were noted at this inspection. The pipes to the wash hand basin in the nurses’ station were leaking, this has led to damage to the wall and the carpet Amesbury Abbey Nursing Home Version 1.10 Page 16 underneath the basin, giving an unsightly appearance and making the area difficult to keep clean. One service user did not have tiling behind their wash hand basin and the paint-work was bubbling and deteriorated, they also had two holes in their wall, next to their bed, both areas need to be attended to before they deteriorate further. The seam in the flooring close to the cookers was no longer intact and debris had built up. The cookers are placed on a tiled plinth and the tile sealing has deteriorated in places, with debris visible. The wheels of the two cookers were not clean. All catering areas must be maintained at high standards of cleanliness and be easy to clean to ensure that contamination is not possible during meal preparation. The walls in parts of the conservatory was deteriorating and cracks were visible in the grout between the floor tiles, one electrical socket had a crack in it. This is unsightly and uneven flooring and unsafe electrical sockets can be a risk to service users. The roof of the conservatory continues to need attention in places and the paint on several exterior windows continues to deteriorate with many windows showing bare wood. At previous inspections it has been recommended that the exterior windows be repainted prior to further deterioration. All service users rent apartments in the home, some of them are large with a hall, sitting room, bedroom and bathroom. Smaller rooms all exceed minimum standards. Service users furnish their own rooms, this means that they are all highly individual in style. Two rooms do not have level floor access, records showed that both service users could climb up and down the flight of stairs to their room, with minimal assistance. There is a drawing room, dining room and conservatory and several service users also like to sit in the entrance hall, which is provided with comfortable furniture. The Abbey had extensive grounds and nearly all room windows have very attractive views. One service user said “We’ve such beautiful views here” and another described the views as “marvellous”. The home now has two bathrooms suitable for disabled persons, one on the ground floor, one on the first floor. Improvements have been made to the bathroom on the second floor but it is not suitable for disabled persons, so service users on this floor still have to go to the ground or first floor if they need assistance with bathing. The owners were required at the previous inspection to submit an action plan to the Commission, detailing how they proposed to improve bathing facilities for disabled service users with rooms on the second floor, by 31st March 2005, they have not done so. Records of bathwater temperatures are not consistently kept, full records were maintained in the second floor bathroom, but not in the ground floor bathroom. Records are made in centigrade and show water temperatures to be within expected ranges. One service user said that the hairdressing room was cold, this was found to be the case at the beginning of the day. Equipment is provided for service users with complex care needs. One service user had an electrically profiling bed. Several service users had low air-loss mattresses. Service users with complex urinary care needs are provided with Amesbury Abbey Nursing Home Version 1.10 Page 17 ventilation systems, to ensure that odour is avoided. One service user said that staff came “very quickly” whenever they rang their call bell. The home was clean throughout. One domestic was observed to be thorough when she performed her duties. The laundry was well organised and clean throughout. Commode buckets were examined during the inspection and while the majority were clean, four were not and a jug used for sanitary care was also not clean. Similar but different issues have been noted at the past two inspections. This is more likely to relate to the lack of an effective mechanical cleaning system for sanitary items than to staff not following their duties. An immediate requirement certificate was issued with a compliance date of 31st May 2005. The owners are advised that enforcement action will take place if systems and/or equipment is not put in place to ensure adequate cleanliness of sanitary items and to ensure that risks of cross-infection are reduced for service users. Amesbury Abbey Nursing Home Version 1.10 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 28 30 Amesbury Abbey are managing to maintain staffing levels so as to meet the needs of service users. Training programmes ensure that staff are competent to meet service users’ needs. EVIDENCE: Amesbury Abbey have Conditions of Registration setting minimum staffing levels from which they must not regress. They are meeting the condition. Two registered nurses have recently resigned, Mrs Collins was optimistic that both vacancies would shortly be filled. This means that at present Mrs Thomas and Mrs Collins are the only full-time registered nurses. Part-time registered nurses are supporting the home in ensuring that all shifts are covered. Mrs Collins reported that the home were nearly up to establishment for care assistants. Staff turnover is what would be anticipated in an area where there is some reliance on a workforce who are related to military personnel and some staff from overseas. There were vacancies for ancillary staff. A training manager is employed, she supports staff in NVQ training. Currently all care staff, apart from those undergoing induction or those who have an equivalent qualification are training or trained to NVQ 2 or 3. Detailed individual training records are maintained for all staff. These show that a range of training is offered to staff, most recent training included training on the management of service users with swallowing difficulties, from the speech therapist. The trainer has not yet been sent on a manual handling training course, as was recommended at previous inspections. Amesbury Abbey Nursing Home Version 1.10 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38 Staff training is taking place, to ensure that there is an awareness of health and safety. There are various areas within the environment which present risks to service users. It is of concern that management have taken little action in the three areas identified, to ensure that service users are protected. EVIDENCE: The training officer ensures that all staff receive mandatory heath and safety training. The manual handling coordinator has not yet been sent on a relevant course as has been recommended at the two previous inspections. Accidents are clearly documented by staff, records reflected in full what two service users described. At the inspection of 21st June 2004, it was identified that, as the home cares for some service users with dual mental health and general care needs, they need to ensure service user safety. The home have installed security systems, use pressure pads if indicated and have alarmed some of the fire exit doors. Amesbury Abbey Nursing Home Version 1.10 Page 20 However four of the fire exit doors have not been alarmed. Fire exit doors open onto a dimly lit internal metal staircase, where a frail service user would be at risk of hurting themselves, additionally some cleaning materials had been left in the stairwell, which could also present a risk to confused service users. At the previous inspection, failure to meet this requirement was identified and an immediate requirement letter issued. The home were required to ensure service user safety by 28th February 2005. At this inspection two service users were identified with dual diagnosis, one service user’s condition was stable on the day of the inspection but their records indicated that this was not always the case. The other service user was restless and wandering throughout most of the inspection. Both service users could have had the potential to wander into the fire escapes. An immediate requirement certificate was issued, with a due date of 31st May 2005. At the inspection of 21st June 2004, the home were required to complete its programme for the installation of protection to hot surfaces by 30th September 2004. At the previous inspection, it was observed that one service user with a risk of falls did not have protection to their radiators and that this had not been considered in their risk assessment. The home were required to ensure that risk assessments considered such risks by 31st January 2005. At this inspection, it was noted that one frail service user did not have protection provided to their radiator and that no risk assessment of this had been made. An immediate requirement certificate was issued, with a compliance date of 31st May 2005. At the inspection of 21st June 2004, it was noted that a large number of carpet joints in communal areas were not secure, which could present a risk of tripping injury to service users with a shuffling gait. At the previous inspection, similar issues continued to be identified and an immediate requirement letter was issued. At this inspection, it was noted that at least nine carpet joints were not secure and an immediate requirement certificate was issued, with a compliance date of 31st May 2005. The owners are advised that the Commission will take enforcement action if adequate steps are not taken to ensure service user safety in the three areas identified above. Amesbury Abbey Nursing Home Version 1.10 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. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION 2 3 2 3 3 2 2 2 STAFFING Standard No Score 27 3 28 3 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x x x N/A x x 2 Amesbury Abbey Nursing Home Version 1.10 Page 22 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard 1 8 Regulation Requirement Timescale for action 31 May 2005 31 August 2005 3. 19 4. 19 5. 19 6. 19 5(1)(d)(2) A full service users guide must be made freely available to each service user. 13(4)(c) Where a service user has 15(1) individual needs relating to prevention of pressure damage, this must always be documented. 23(2)(d) All worn, stained and deteriorated carpets must be replaced. (This requirement was identified at the previous inspection, it is not yet due) 23(2)(b) The leaking pipes round the wash hand basin in the nurses station must be repaired and the damaged wall and carpet behind and under the area made good. 23(2)(b) One service users room, which (d) was identified during the inspection must have the area behind the wash hand basin repared and tiled and the holes in the wall by their bed made good. The cracked electrical socket in the conservatory must be repaired. 13(3) The joints between the flooring 23(b)(d) in the kitchen and in the tiling under the cookers must be Version 1.10 30 September 2005 31 May 2005 31 May 2005 31 May 2005 Amesbury Abbey Nursing Home Page 23 7. 19 23(2)(b) (d) 33(2)(j) (n) 8. 21 9. 10. 25 26 23(2)(p) 13(3) 23 (2)(k) 11. 38 13(4)(a) (b)(c) cleaned out and re-sealed. The cooker wheels must be fully cleaned. An action plan for redecoration and mending the floor of the conservatory must be submitted in writing to the Commission. An written action plan must be submitted to the Commission, detailing how adequate assisted bathing facilities are to be provided for disabled persons who live on the second floor. The action plan for the second floor bathroom must include how access is to be provided to the bathroom for service users who are unable to mobilise up and downstairs. (Parts of this requirement were identified at the previous two inspections, with a compliance date of 31 March 2005 and has not been met.) Adequate heating must be provided in the hairdressing room. Safe systems, which conform to principals of prevention of spread of infection, must be in place for all sanitary items, to ensure that they are clean, free of staining and fully dried. (This requirement has been identified at the previous two inspections. A compliance date of 28 Feburary 2005 was set and has not been met) An alarm system must be put in place on doors to fire escape stairs to ensure that staff are alerted if service users wander into these areas. (This requirement has been identified at the previous two inspections. A compliance date of 28 Feburary 2005 was set and has not been met). Version 1.10 31 May 2005 31 May 2005 30 August 2005 31 May 2005 31 May 2005 Amesbury Abbey Nursing Home Page 24 12. 38 13(4)(a) (c) 13. 38 13(4)(a) (c) Individual service user risk assessments must include an assessment of the risk presented by unprotected radiators to a service user and where risk is identified, action must be taken to reduce risk. (This requirement was identified at the previous inspection. A compliance date of 31 January 2005 has not been met). All carpet joints must be made secure. (This requirement has been identified at the last two inspections. A compliance date of 14 January 2005 has not been met) 31 May 2005 31 May 2005 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. Refer to Standard 12 Good Practice Recommendations The persons registered should send the person who is responsible for activities on an activities co-ordinators course, to extend and broaden their skills and knowledge base. (This recommendation has been identified at the past two inspections and has not been actioned.) The persons registered should consider ways of identifying rooms to service users and staff. They should also consider the introduction of name badges for staff. (This recommendation has been identified in part for the past two inspections and has not been actioned). A system should be put in place to ensure that all service users are informed of what is for lunch. Where concerns are recorded, outcomes and actions should also be documented. The persons registered should plan a programme to redecorate external windows and the roof of the conservatory before their condition deteriorates further. (This recommendation has been identified at the past two inspections and have not been actioned). Regular audits of bathwater temperatures records should Version 1.10 Page 25 2. 14 3. 4. 5. 15 16 19 6. 25 Amesbury Abbey Nursing Home 7. 29 8. 38 take place, to ensure that all staff are conforming to the homes policy. The persons registered should use their interview assessment tool when assessing prospective employees at interview. (This recommendation was identified at the previous inspection, it was not reviewed at this inspection). The persons registered should send the manual handling co-ordinator on a relevant course. (This recommendation has been identified at the previous two inspections, it has not been actioned). Amesbury Abbey Nursing Home Version 1.10 Page 26 Commission for Social Care Inspection Suite C, Avonbridge House Bath Road Chippenham Wiltshire, SN15 2BB 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 Amesbury Abbey Nursing Home Version 1.10 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. 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