Inspection on 24/01/07 for The Abbey Retirement Home

This inspection was carried out on 24th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

The Abbey Retirement Home 09/04/08

The Abbey Retirement Home 22/08/07

The Abbey Retirement Home 11/01/06

The Abbey Retirement Home 14/04/05

The Abbey Retirement Home 15/12/04

The Abbey Retirement Home 25/05/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE The Abbey Retirement Home 348 Winchester Road Southampton Hampshire SO16 6TW Lead Inspector Jan Everitt Unannounced Inspection 24th January 2007 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 The Abbey Retirement Home DS0000011849.V323027.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. The Abbey Retirement Home DS0000011849.V323027.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Abbey Retirement Home Address 348 Winchester Road Southampton Hampshire SO16 6TW 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) 023 8070 2671 Mr Roy Clive Northover Mrs Heather Northover Care Home 15 Category(ies) of Dementia - over 65 years of age (15), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (15), Old age, not falling within any other category (15) The Abbey Retirement Home DS0000011849.V323027.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. A maximum of 3 service users in the categories DE and MD may be accommodated between the age of 55-64 years at any one time 11th January 2006 Date of last inspection Brief Description of the Service: The Abbey Retirement Rest Home is a home that can accommodate up 15 elderly ladies and gentleman, some with associated dementia. Mr & Mrs Northover, who are the registered persons for two other rest homes in the Southampton and Eastleigh Locality own the Abbey Retirement Rest Home. The home is situated in an affluent area of Southampton, near to the Common, popular sports centre and close to both Southampton Town Centre and Shirley High Street. There is a small parade of local shops that cater for most emergency supplies. The home is also closely situated near to the Southampton General Hospital and is on a main bus route from Shirley and Southampton allowing easy access into work for staff. The Abbey Retirement Rest Home is in keeping with neighbouring homes and is maintained inside and has an attractive enclosed garden that attracts the sun all day in the spring and summer months. The Abbey Retirement Home DS0000011849.V323027.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced site visit to Abbey Retirement Home took place on the 24 January 2007, and was attended by one inspector over a period of seven hours. Throughout the visit the manager was available and the staff assisted the inspector in general. The visit to Abbey Retirement Home formed part of the process of the inspection of the service to measure the service against the key national minimum standards for the year 2006/7. This report details the results of an evaluation of the quality of the service provided by Abbey Retirement Home and brings together accumulated evidence of activity in the home since the last key inspection in January 2006. The judgements made in this report were made from the visit to the home, information gathered prior to the visit; pre-inspection information submitted to the commission by the registered manager, information from the previous report, the service history correspondence, registration activity, touring the home and viewing records. People who use the service have been consulted with and this has been done by questionnaire surveys sent to service users, relatives, other visiting professionals including GPs, staff questionnaires and talking to service users and staff at the time of the inspection visit. Due to the service user’s cognitive impairments only four comment cards were completed. The responses from the surveys were, in general, very positive. The inspector sat in the main lounge area and observed the routines and care practices in the home and how care staff and service users interacted. This visit focused on the core standards to be assessed on this visit. What the service does well: The home has a comprehensive pre-admission procedure that ensures service user’s needs can be met. The environment provides a warm, comfortable home for the service users. Service users report that they are happy with the environment and quite comfortable ‘although it is not home’. A relative spoken with said that she was more than happy with how the home cared for her mother and the accommodation provided. The Abbey Retirement Home DS0000011849.V323027.R01.S.doc Version 5.2 Page 6 The home maintains a good standard of hygiene. The service users have care plans that describe their needs and how their needs can be met. These are reviewed appropriately. Service users health and social care needs are met. The home has an activities programme in place in which service users have the choice to participate. Service users report that they consider their privacy is respected and that they are able to make choices within the activities of their daily living. Service users comments indicate that the staff are available and service users consider there are sufficient staff on duty to meet their needs. Staff comment cards and those spoken with report that they receive a variety of training and are supervised at regular intervals where their training needs are discussed. The new manager demonstrated good relationships with the service users and was sensitive to their varying needs. Staff spoke highly of the manager and consider they are well supported by her. What has improved since the last inspection? What they could do better: There are areas of the home that are in need of redecoration and refurbishment, the kitchen storage cupboards and flooring being the main concern. The laundry room sink area is also in urgent need of repair. The manager has no designated time or accommodation to undertake the management and administration duties of her role with these mainly taking place at the kitchen table whilst she is part of the working numbers for caring for the service users and is continually disturbed. The Abbey Retirement Home DS0000011849.V323027.R01.S.doc Version 5.2 Page 7 It is unfortunate that the home has no separate area for activities or a separate television area as service users have little choice if one service user wishes to look at the television. The laundry room must be secured whilst there are detergent liquids being stored on the floor inside the door. A risk assessment must be undertaken and a care plan written to enable one service user who chooses to self medicate once a day. The manager must dispose of all the old out of date dressings and medical testing equipment that is stored in the cupboard in the ground floor toilet. Stocks of prescribed items must not be kept as stock and must only be used for the service user for which they are prescribed. Soap dispensers must be fitted in all toilets and bars of soap disposed of. The results of the service user survey undertaken by the home should be analysed and the results published to demonstrate that the home is fulfilling the home’s Statement of Purpose and that service users have input into the running of the home. The recruitment practices of the home must be more robust. All documentation and appropriate checks must be recorded in staff personnel files as stated on Schedule 2 of the Care Home Regulations. It is the responsibility of the registered manager to ensure that all the necessary documentation is in place before employment commences. This was also made a requirement of the report of January 06 and has been made an immediate requirement of this inspection visit. 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 The Abbey Retirement Home DS0000011849.V323027.R01.S.doc Version 5.2 Page 8 be made available in other formats on request. The Abbey Retirement Home DS0000011849.V323027.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 The Abbey Retirement Home DS0000011849.V323027.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users needs are assessed prior to being admitted to ensure the home can meet those needs. EVIDENCE: A sample of 6 care plans was viewed for pre-admission assessment. The two most recent admissions were part of the sample. In general the pre-admission assessment was comprehensive and covered most aspects of care. The manager undertakes the assessment, usually in a clinical area and therefore information is gathered from the hospital care plans, family and the social worker. The manager reports that care manager’s needs assessments are not consistently received by the home. Potential service users will be invited into the home prior to admission, if this is possible and they choose to do so. The Abbey Retirement Home DS0000011849.V323027.R01.S.doc Version 5.2 Page 11 A married couple who are recently admitted service users, were spoken with. The husband said he had chosen to visit the home prior to being admitted. The wife had declined but now verbalised that she wished she had as she would have felt better prepared for moving from her home into care. She felt there were not many people she could talk to, but felt fortunate that she had made friends with the lady that sat next to her in the lounge The Abbey Retirement Home DS0000011849.V323027.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service user’s health, personal and social care needs are described in individual care plans. The homes policies and procedures for the management of medication do not consistently protect the service user. Service users are treated with respect but their privacy is not consistently upheld. EVIDENCE: A sample of four (4) service users care plans were viewed. The care plans are stored in a cupboard in the kitchen area and staff have to cross the kitchen to access them. Staff confirmed that they had full access to care plans and that they were kept informed of any changes to residents support needs. Daily records are maintained to record any changes. The Abbey Retirement Home DS0000011849.V323027.R01.S.doc Version 5.2 Page 13 Two of the four service users’ plans viewed by the inspector had not had a full admission assessment undertaken. The plans evidenced that reviews of the care plans are undertaken monthly. The inspector observed that one service user was being seen by the district nurse to have her leg dressed regularly but there was no record to identify this was taking place. The inspector observed that care plans were providing sufficient detail and guidance to enable staff to recognise and support residents with their mental health needs, although social histories were not being recorded consistently. In general the care plans were detailed enough to inform day-to-day practice and for the care needs of the service users to be identified. The service users spoken with informed the inspector that they had access to a range of healthcare support and that the home was’ good at getting the doctor when you needed one’. At the time of the inspection a chiropodist was visiting the home to see one service user who had made the choice of which chiropodist she wished to use. The regular visiting chiropodist sees the other service users every 6 weeks. The manager reported that the home has access to community psychiatric services should she request a service user to be reviewed. The manager reports that the community rapid response team are excellent at responding to referrals if a service user’s mobility needs reassessing. Care plans document that service users are receiving their national health entitlements. The home maintains the medication in a locked cupboard under the stairs. The home has a medication policy in place. The home uses a monitored dosage system and the inspector did not observe any large stocks of other medication being maintained in the home. The manager described the process for the ordering and checking of medications when they arrive in the home to ensure that the medication ordered is what is delivered. She reported that the returns of unwanted medication takes place once a month and the inspector evidenced the book that records this. The inspector viewed the MAR sheets, which were completed appropriately. The inspector viewed the cupboard in the downstairs toilet where dressings and other associated equipment are stored. A large number of dressings were well out of date and the inspector informed the manager that these must be destroyed if no longer in use. This would eliminate possible risk of the product being used whose quality could no longer be guaranteed and if used could be to the detriment of the service users health and safety. The Abbey Retirement Home DS0000011849.V323027.R01.S.doc Version 5.2 Page 14 There is one service user who is administered her medication in the morning and keeps one to self-medicate later in the day. There is no risk assessment or care plan to guide and inform how this practice is being managed. A requirement will be made from these findings. The inspector sat in the lounge area with the service users for a period of time. The service users were interacting well with the staff and it was obvious that staff were familiar with the needs and the daily routines of the service users. Staff were overheard giving service users support and encouragement to mobilise and treating them with respect. The inspector observed that a service user was using another service user’s bedroom to be seen by the chiropodist. When this was discussed with the manager she reported that the service user had given permission for this to take place so as to avoid the other service user having to go upstairs to her room. The inspector will recommend this be documented appropriately. The service users spoken with reported that the carers were ‘good’ and they felt respected by them and ‘their wishes were heard’. The Abbey Retirement Home DS0000011849.V323027.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have the opportunity to engage in different activities, and make their own decisions about how they spend their time. Service users are supported to maintain contact with family, friends and the local community. Service users have choice and autonomy of how they wish undertake the activities of daily living. The meals in the home are good, offering both choice and variety. EVIDENCE: Service users have the opportunity to engage in various activities. The home has twice weekly outside entertainers come to the home. On the day of the The Abbey Retirement Home DS0000011849.V323027.R01.S.doc Version 5.2 Page 16 inspection visit a lady attended the home to provide music for health. She spoke with the inspector and described how with music she encouraged the service users to participate in singing and exercise and provides musical instruments for people to use. The inspector participated in the group and observed that service users were participating and enjoying the session to the best of their capabilities. It certainly stimulated their senses. The inspector considered it unfortunate that the activities take place in the one through lounge, which houses the televisions, one at each end. One service user had chosen not to join in with the musical activities and requested that the television remain on. This did detract from some of the group participation. Another very elderly lady objected to the music and requested she be taken back to her room whilst it was going on. Service users that were spoken to at the time said they were happy with the level of activities that took place in the home. The manager reported that most days something is going on such as quizzes or games and carers were observed sitting talking to service users during the afternoon period. Service users also have the opportunity to attend church communion at the home and attend outside churches if they choose. The inspector observed that visiting times were displayed on the notice board. Service users may choose to entertain their visitors in their rooms or in the dining room. This can be difficult as the dining room also houses a large cupboard that contains the home’s computer and telephone/fax machines and is periodically being used by the manager or staff. Most of the bedrooms are double and therefore privacy is not always guaranteed. The inspector observed that the home is visited regularly and on the day of the inspection visit there were two relatives visiting in the lounge. Both spoke to the inspector and expressed great satisfaction with the care their loved ones were receiving in the home. The inspector observed that service users were being offered choices of where they chose to sit and how they wish to undertake the activities of their daily lives. Service users spoken with told the inspector that they were free to please themselves how they spent their day and that they did not have any restrictions. The kitchen was visited and the cook for the day was spoken with. She told the inspector that although there is a menu plan it can vary from day to day but records are maintained of what the service users eat. On the day of the visit the meal was a roast dinner. The inspector observed that there were fresh vegetables and the meal was presented well and served out individually from a trolley. The service users eat well and they told the inspector that the food was ‘excellent’ and that they get ‘plenty of it’. This was confirmed on observation. The Abbey Retirement Home DS0000011849.V323027.R01.S.doc Version 5.2 Page 17 The cook reported that a service user could have any alternative they choose, as being a small home this was possible. The inspector observed that a pureed meal was being stored in the fridge. This was unlabelled and was reportedly to be going into the freezer. The inspector considered this not appropriate and that it should be destroyed. One person was taking a diabetic diet that the cook said was mainly being managed with diabetic puddings. Service users weights are monitored regularly. The manager reported that all staff have undertaken the food handling and hygiene training because all members of staff do at some time cook, serve and handle the food. The Abbey Retirement Home DS0000011849.V323027.R01.S.doc Version 5.2 Page 18 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are confident that their complaints or concerns will be heard and acted upon. The home has policies and procedures are in place to protect service users from abuse. EVIDENCE: The complaints procedure was on display in the front hallway. It informs service users, relatives and staff of their rights to complain and how to do so. There have not been any complaints since the last inspection. Service users spoken with told the inspector that the manager is very approachable and that they would speak to her if they wished to discuss any issues. The returned surveys distributed by the CSCI to service users all indicated that they would know how to make a complaint. A number of the service users in residence would be unable to advocate for themselves owing to their lack of mental capacity. The manager is aware of the adult protection procedure and has a copy of the Local Authority’s procedure. The manager ensures that staff undertake The Abbey Retirement Home DS0000011849.V323027.R01.S.doc Version 5.2 Page 19 training on this procedure at the time of their induction and also this issue is discussed at the three monthly staff meetings. The manager is very aware of the importance of this training as the home had to initiate the procedure following an incident last year, which she dealt with appropriately. Service users said they felt safe in the home and the staff spoken to demonstrate that they were aware of the home’s policy and procedure when dealing with adult protection. The Abbey Retirement Home DS0000011849.V323027.R01.S.doc Version 5.2 Page 20 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. High standards of hygiene are maintained throughout the home. The environment is homely, comfortable and safe for service users to live in. EVIDENCE: The inspector toured the home. The home was very clean and no offensive odours could be detected. The home is quite pleasantly decorated with areas in the hallway and lounge having been identified as in need of redecoration. The Abbey Retirement Home DS0000011849.V323027.R01.S.doc Version 5.2 Page 21 The garden is pleasant and used in the finer weather and at the time of this visit the gardener was attending to outside area, cutting bushes and making the garden ready for the better weather. The home has a maintenance book in which jobs are documented and when completed by the maintenance man are signed off. The maintenance man services the three homes in the group and as a consequence only attends this home when there are a number of jobs to be done. The workbook therefore reflects that the some jobs from October have not yet been completed. The inspector observed that the laundry on the first floor was very small. The sink surround in the laundry was in need of re-plastering as the wall was crumbling, looked unsightly and is a harbour for bacteria in an area that should be clean. This had been requested by the manager to be attended to in October. The manager reported that there is a policy for dealing with fouled linen. The inspector observed that the door to the laundry was left unlocked and housed washing fluids that should have been stored in a safe environment. The inspector viewed many of the service users bedrooms that were observed to be comfortable and in most cases had been personalised with their own belongings. One of the married couples living in the home has made their room very homely. The inspector observed that the hallway carpet was discoloured in areas and looked unsightly. The manager reported that bleach had been spilt on it over time and that it did need replacing. She reported that the lounge and hallway are scheduled to be redecorated soon. The manager reported that the provider decides on a redecoration programme as and when it is needed. The provider’s son does tour the home monthly to identify any maintenance needs and to discuss what repairs are needed in the home. A tour of the kitchen revealed that the kitchen is in a poor state of repair. The work surface in one area is burnt and kitchen units were broken with fronts of units and draws hanging off. The Environmental Health Inspector visited in May 2006 and left a report that identified two requirements and seven recommendations. The inspector observed that the kitchen flooring was torn and presented a health and safety hazard to both staff and service users, who were observed by the inspector to go into the kitchen freely. The inspector observed that the cleanliness of the home was maintained to a good standard the home was fresh and clean. The surveys returned to the The Abbey Retirement Home DS0000011849.V323027.R01.S.doc Version 5.2 Page 22 CSCI from service users indicated that they consider the home to be ‘very clean at all times’. An infection control policy is in place and training for this takes place via a video and test questionnaire. The staff were observed to be following policy and were wearing aprons and rubber gloves appropriately. Aprons were changed appropriately for personal care and serving food. Hand washing facilities were observed to be available around the home. The inspector observed that a soap dispenser was not available in the first floor bathroom. The inspector advised the manager to get rid of the bars of soap, as these could be a source of spreading infection. The cleaning of the home is allocated to one of the carers on duty each day, which maintains the good standards of cleanliness. The Abbey Retirement Home DS0000011849.V323027.R01.S.doc Version 5.2 Page 23 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): Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The number and skill mix of staff on duty meets Service users needs. Staff have been trained appropriately to care for the client group. The recruitment procedures and practices do not protected service users. EVIDENCE: The staff rotas were examined. The staff identified on duty each day undertakes the caring, cooking and cleaning and this is allocated on a daily basis. The rotas identified that for the thirteen service users in residence at the time of this visit, four staff were on duty in the morning, three until 16.00 and two in the evening and one waking/one sleeping staff throughout the night. The inspector identified that some staff were working from 16.00 until 08.00 the next morning, and this being the waking staff for the night. This was discussed with the manager as being unacceptably long hours for one staff member to work in one go and that this could compromise the carers capabilities and decision making if she was tired and the only member of staff on duty awake. The Abbey Retirement Home DS0000011849.V323027.R01.S.doc Version 5.2 Page 24 The inspector also noted that the manager has no protected time during the week to undertake her management duties. This has been highlighted in a previous report and a requirement was made. The pre-inspection questionnaire reported that 62 of staff have achieved their NVQ level 2 and 3 and another three are anticipating undertaking their level 3. A sample of three recruitment files was viewed. The recruitment practices are poor. From viewing the files it was discovered that two of the care workers CRB checks had not been received. One staff had no POVA check and all three passports could not identify that the carers were permitted to work in this country. This was discussed at length with the manager and an immediate requirement was made from these findings stating that until these checks were carried out and proof of the staff’s residency in this country, proved, the staff must work under supervision. This highlighted further concerns with the home’s recruitment practices as a requirement was raised from the previous inspection report of January 06 when it was required that all appropriate checks be completed before care staff commence employment. The inspector evidenced the training records. These demonstrated an appropriate variety of training provided for staff. The manager reported that she has planned medication training by the local pharmacist that will be undertaken by carers using workbooks to work through to test knowledge. The manager evidenced that the mandatory training for health and safety is in place but also identified that the moving and handling was over due but had been booked to take place imminently. Staff spoken with confirmed that training is available and they are supervised and appraised regularly and that training is provided. The inspector evidenced the supervision notes in the personnel files. The Abbey Retirement Home DS0000011849.V323027.R01.S.doc Version 5.2 Page 25 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager is accessible and sensitive to the needs of service users, although restricted accommodation and time does not allow her to undertake her management role fully. The home does have a quality assurance system in place. Service users financial interests are safeguarded. The health and safety of the service users and staff are promoted. EVIDENCE: The Abbey Retirement Home DS0000011849.V323027.R01.S.doc Version 5.2 Page 26 The manager is now registered with the CSCI. She has been working at the home for some years and therefore has a considerable amount of experience with this client group. The manager has obtained her registered managers award and intends to undertake the NVQ level 4 in care. The inspector observed that the manager works very much as part of the team and does not allow herself protected time for her management duties. From speaking with staff and observation, the staff respect the manager who is accessible and sensitive to the service users’ needs that are in residence. However, attention needs to be paid by the manager to the outstanding requirements as detailed in this report. The manager has no designated area to undertake the management administration of the home. The dining room houses a large cupboard in the corner in which the computer and the telephone is stored. The care plans are housed in a kitchen cupboard and medication is stored under the stairs, therefore most of the administration is undertaken in the kitchen. The manager reported that the provider has offered her office space on the top floor but she considers she will be isolated and away from the service users. This was discussed with her and consideration must be given to providing office space to allow the manager to communicate with service users, relatives and staff in confidence. The home has a quality audit system in place. The manager reviews care plans monthly and questionnaires are distributed to service users and relatives every six months. The results of this questionnaire has not been analysed but the inspector viewed the replies and the manager described how she has responded to suggestions made in the responses. The proprietor’s son visits the home monthly to undertake a monitoring visit to monitor the environment. A copy of the report from this visit is submitted to CSCI. The inspector observed that there were areas of the home particularly the kitchen area that was in need of refurbishment and repair and that had not been acknowledged in the quality control report. The home does look after four service user’s monies. These were checked by the inspector and observed to be stored in individual containers and records maintained of all incoming and outgoing money. The balance of monies agreed with the records. The fire log was viewed by the inspector who observed that the fire alarm and detection equipment have been checked at appropriate intervals. The home has not obtained a copy of the new fire regulations and the manager reported that the provider would down load a copy from the Internet. The home has a fire risk assessment. The Abbey Retirement Home DS0000011849.V323027.R01.S.doc Version 5.2 Page 27 A sample of servicing certificates were viewed and observed to be current. The passenger lift engineer was present in the home on the day of the visit undertaking a service. The Abbey Retirement Home DS0000011849.V323027.R01.S.doc Version 5.2 Page 28 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 2 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 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 The Abbey Retirement Home DS0000011849.V323027.R01.S.doc Version 5.2 Page 29 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 OP9 Regulation Reg 13(4)c Requirement The registered manager must ensure that all ‘out of date’ wound dressings that have been prescribed by the GP at some time, and no longer in use, be destroyed. The registered manager is required to undertake a risk assessment and a care plan documented to guide practice when a service user wishes to maintain their own medication. The registered manager is required to make arrangements for the laundry door to be locked at times a member of staff is not in attendance, to ensure that washing chemicals are stored securely. The registered manager is required to make arrangements for the repair of the wall and surround to the sink area in the laundry. The providers are required to make the kitchen fit for purpose and make good the broken kitchen cupboards, draws and work surfaces that are burnt. DS0000011849.V323027.R01.S.doc Timescale for action 28/02/07 2. OP9 Reg 12(2) 28/02/07 3. OP19 Reg 13(4)(a) 28/02/07 4. OP19 Reg 23 (2)(b) 31/03/07 5. OP19 Reg 13(4) Reg 23(2) 30/04/07 The Abbey Retirement Home Version 5.2 Page 30 6. OP27 Reg 18(1)(a) 7. OP29 19 (1) (b) The kitchen flooring is in a poor state of repair and leaves staff and those service users who visit the kitchen regularly, at risk of tripping. This must be replaced. The registered manager is 31/03/07 required to ensure that the home is staffed with appropriate competent numbers of staff that are not working unrealistically long waking hours, taking into account the guidance in the working time directive. The registered manager must 28/02/07 ensure that recruitment practices and procedures are robust and that staff must not commence work at the home until all satisfactory checks have been made in line with the regulations. This was a requirement from the inspection of January 06 with timescale of 01/02/06 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 OP3 Good Practice Recommendations It is advised that care management assessments are obtained for any prospective resident whom is either fully or partially funded. It is recommended that the arrangements and agreement from the service user should be documented in the care plans of the service user whose room is used by the chiropody for another service user. It is recommended that a soap dispenser be fitted in the DS0000011849.V323027.R01.S.doc Version 5.2 Page 31 2. OP10 3. OP26 The Abbey Retirement Home 4. OP31 first floor bathroom and all bars of soap be removed. It is recommended that protected management time be identified on the staff rotas and the manager is not counted in the numbers for a minimum of two shifts per week. It is recommended that the manager be allocated an area in the home to enable her to undertake her management and administration duties away from the hub of the work place. This would also enable her to retain confidentiality when speaking with service user, relatives and also supervising staff. It is recommended that the manager/provider analyses the responses from the service users questionnaires that are distributed by them, and publish the results as to how the home is succeeding in fulfilling its Statement of Purpose. 5. OP33 The Abbey Retirement Home DS0000011849.V323027.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 The Abbey Retirement Home DS0000011849.V323027.R01.S.doc Version 5.2 Page 33 - 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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