Inspection on 22/08/06 for Abberton Manor Nursing Home

This inspection was carried out on 22nd August 2006.

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

Other inspections for this house

Abberton Manor Nursing Home 16/10/08

Similar services:

Claremont House

Sun Court Nursing Home

Bramley Avenue (73)

15 Bramble Close

Dolphin Court

Fen Road

Wakes Hall

165 Putnoe Lane

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

CARE HOMES FOR OLDER PEOPLE Abberton Manor Nursing Home Layer Road Abberton Colchester Essex CO5 7NL Lead Inspector Diane Roberts Final Unannounced Inspection 22nd August 2006 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Abberton Manor Nursing Home DS0000065842.V309378.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. Abberton Manor Nursing Home DS0000065842.V309378.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abberton Manor Nursing Home Address Layer Road Abberton Colchester Essex CO5 7NL 01206 735590 01206 736078 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) Frontsouth Limited Miss Elizabeth Anne Davida Pearson Care Home 26 Category(ies) of Physical disability (6), Physical disability over 65 registration, with number years of age (26), Terminally ill (14) of places Abberton Manor Nursing Home DS0000065842.V309378.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. Persons of either sex, aged 45 years and over, who require nursing care by reason of a physical disability (not to exceed 6 persons) Persons of either sex, aged 65 years and over, who require nursing care by reason of a physical disability (not to exceed 26 persons) Persons of either sex, aged 35 years and over, who require general palliative care (not to exceed 14 persons) One named person, aged 32 years and over, who requires nursing care by reason of a physical disability One service user aged 25 years who requires respite care by reason of a phsyical disability whose name was provided to the Commission in August 2006 The total number of service users accommodated in the home must not exceed 26 persons New Service Date of last inspection Brief Description of the Service: Abberton Manor is a large converted house set in an attractive garden and rural area on the outskirts of a small village near Colchester. The home has a car park but is not within local bus routes. The home has a large garden to the rear with a patio and further gardens at the side and front, which give views over the surrounding countryside. The home primarily provides care for older people, with physical disabilities but also provides palliative care and care for severely brain injured people. More recently the home has applied for variations to allow them to take younger adults with complex nursing needs and this has worked well with the current resident group. The current scale of charges is from £695.00 to £750.00 per week. There are additional costs for items such as hairdressing, toiletries, chiropody, guest meals and newspapers. Information is made available to prospective service users via a Service Users Guide, which will be available prior to admission. Abberton Manor Nursing Home DS0000065842.V309378.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over seven hours and was carried out as part of the annual inspection programme for this home. The registered manager was available during the inspection and this was her first inspection as registered manager. This was the first key inspection for this home with new owners. The inspection focused upon all of the key standards. A partial tour of the premises was undertaken. Evidence was also taken from the Pre Inspection Questionnaire completed by the home and submitted to the CSCI. Three residents, two visitors, and three staff were spoken to during the inspection. Five resident comment cards from the CSCI were returned and comments from these were taken into account when writing the report. What the service does well: What has improved since the last inspection? This is the first inspection with the new owners and manager, therefore no previous inspection report is taken into account. However, it is clear that both have made improvements to the care and facilities provided at the home. Residents and relatives feel that the changeover to the new owners has been smooth and stress free. Abberton Manor Nursing Home DS0000065842.V309378.R01.S.doc Version 5.2 Page 6 What they could do better: 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. Abberton Manor Nursing Home DS0000065842.V309378.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Abberton Manor Nursing Home DS0000065842.V309378.R01.S.doc Version 5.2 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 the following standard(s): 1 and 3. Standard 6 is not applicable to this home. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst information is made available this is limited as it is currently under review. Prospective residents are properly assessed prior to admission to the home. EVIDENCE: The manager is currently reviewing both the Statement of Purpose and Service Users Guide. She has also developed a welcome pack to the home, which contains some aspects of the required information. At the time of assessment, the homes brochure, now out of date, is taken for information and the assessor gives an informal talk on the home. The manager needs to give thought about how to make the Statement of Purpose and Service Users Guide more available to purchasers, residents and prospective residents. The manager has reviewed and updated the homes pre-admission assessment form. This meets all the requirements under this standard. The manager tends Abberton Manor Nursing Home DS0000065842.V309378.R01.S.doc Version 5.2 Page 9 to assess all prospective residents but other qualified nursing staff may also take on this role if required. Completed assessments chosen at random show detailed and informative assessments with a good level of individual information. Records also show a good level of liaison with other agencies in order to obtain information to help their assessment. One assessment was seen to be very informative and insightful, clearly identifying care and social needs relating to the individual. Residents spoken to confirm that they met someone from the home and were assessed prior to coming into the home. Abberton Manor Nursing Home DS0000065842.V309378.R01.S.doc Version 5.2 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 the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a new care planning system in place that is developing well. Resident’s health care needs are met in a proactive way. The medication systems are in good order. Resident’s privacy and dignity is respected. EVIDENCE: The manager has recently introduced a new care planning system, which is developing well. Records and assessment forms have been updated or introduced which give a fuller picture of the residents care. From discussion with residents, it is clear they understand the care they are receiving, including medication, but there is no recorded evidence that either they or their representative have been involved in their actual plan of care. This must be addressed wherever possible. The new system is set into sections and covers activities of daily living and with this home, pain, sleep, spirituality and death. Abberton Manor Nursing Home DS0000065842.V309378.R01.S.doc Version 5.2 Page 11 Care plans were seen to be in place for all the assessed/identified care needs. Where possible objectives have been put in place. Regular reviews and evaluations of the care plans were seen, often completed every few days as things change. Where appropriate, statistics and close monitoring is being undertaken to help feedback to medical staff on specific issues. Care plans were seen to be detailed and informative, backed up by good daily records. A good range of assessment tools are being used and this is the area that needs some work. It was noted that there is no recorded evidence that these are being reviewed and this was discussed with the manager. The team must also check that all the necessary risk assessments, with particular reference to manual handling and bed rails are completed upon admission and updated if necessary. Records show that the team have a very proactive approach to the healthcare needs of residents. A significant number of people are nursed in bed and at the current time, no residents have pressure sores. The home provides a good range of pressure relieving equipment. The manager has recently updated the wound management documentation and this now includes more measurement recording. This record also identifies the cause of the wound and could be used as part of the quality assurance systems for the home. At the current time the nursing staff are only dealing with one longstanding wound. Staff spoken to showed a good awareness of the content of the care plans. Records show that residents are seeing the GP in a timely and proactive manner. Records also show that the home uses and has good links with other healthcare professionals such as dieticians and Macmillan nurses. Records evidence that a chiropodist visits the home on a regular basis although some residents choose to retain their own private chiropodist. The home uses a private Physiotherapist, which residents pay for and referrals can come from the home or the GP. The physio feels that the staff know the residents well and communicate with her as required. She also stated that anything that needs attending to is done promptly and records show that advice given is recorded in the care plans. Records show that wherever possible residents are being weighed and nutritional risk assessments are in place. Medication systems in the home were inspected and remain in good order. On the day of the inspection, the member of staff responsible for the medication system was in the home undertaking a full audit. This is seen as good practice. MAR sheets were seen to be well maintained, neat and clear. The home is still using a bottle to mouth system. The home has yet to develop a self-medicating risk assessment and this was discussed with the manager. Records show evidence of medication reviews and discussion with residents also evidences this, as they are well informed regarding their medication. The use of skin creams was discussed in relation to sore skin and pressure sore Abberton Manor Nursing Home DS0000065842.V309378.R01.S.doc Version 5.2 Page 12 prevention. Whilst there are no residents with pressure sores, the nursing staff at the home do need to make sure that they are clinically up to date with the research/rational for using specific creams. Both residents and relatives feel that the standard of care offered at the home is very good and some relatives commented how much their relative had improved since coming to the home. Residents spoken to state that staff always treat them with respect and are very good at maintaining and letting them have privacy. Interaction between staff and residents was heard to be caring and respectful. Abberton Manor Nursing Home DS0000065842.V309378.R01.S.doc Version 5.2 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 this service. Social activities in the home meet the needs of the current residents but records could improve. Residents have good contact with family and friends. As far as possible, residents are helped to exercise choice and control over their lives. The food provided is good and enjoyed by residents. EVIDENCE: The home has an activities officer in post. On the day of the inspection, the activities officer was on leave; despite this four activities were planned for the week. Residents and relatives spoken to are happy with the current provision at the home and records are in place, which record the plan for the week. The manager and activities officers are working on a new assessment form and recording format, linked into the care planning system. They hope to develop the activities further offering a very flexible approach due to the wide range of differing needs the residents at the home have. Abberton Manor Nursing Home DS0000065842.V309378.R01.S.doc Version 5.2 Page 14 The home has an open visiting policy and residents feel that their family and friends are made welcome and relatives spoken to felt comfortable to visit at any time and said that they were always offered a drink. Relatives felt that communication from the staff at the home was always good. Residents spoken to say that they have choice as to how they spend their day and that staff are flexible and happy to alter their plans if they are not ready to have personal care help. Residents spoken to were all aware of the care they needed and were receiving and the choices they had around that including the level of independence they could achieve and in relation to their medication, especially pain relief. Advocacy information is available in the service users guide, although at the current time this is not widely available in the home. No inventories were seen in care plans of resident’s belongings upon admission. It is recommended that these be developed. Where appropriate, in line with the objectives for the resident, the team have put in place a rights and responsibilities contract regarding the management of a resident’s medical condition. Both the key nurse and resident have signed this agreement. The standard of meal provision in the home remain good. Residents spoken to are happy with the food service at the home. Many of the meals are homemade including soups. Good nutritional records are in place which detail what the resident has chosen and whether they ate well. Special diets are catered for including low protein and diabetic. Residents state that alternative meals are available should they so wish or that the chef will change the meal slightly for them if needed. One resident said that a meal always kept for them if they have been to hospital for an appointment. Residents said that the menu is varied and often changes and that the quality of the food is good. Abberton Manor Nursing Home DS0000065842.V309378.R01.S.doc Version 5.2 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 good. This judgement has been made using available evidence including a visit to this service. The home has systems in place to help ensure that concerns and complaints will be listened to and acted upon. The home has systems in place, which help to ensure the protection of vulnerable adults from abuse. EVIDENCE: The home has an up to date complaints procedure in place. This was seen to be appropriate and displayed in the home and will be available in the new Service Users Guide. The manager has a system in place for logging complaints – to date none have been received. Residents and relatives spoken to were well aware of who they would raise any concerns with. The manager has recently introduced new compliments and complaints comment book, which is left in the reception area. Very good comments were seen from relatives praising the care and understanding of staff, stating that ‘staff are friendly and courteous’, there are ‘high standards of care’ and ‘very clean with no smells’. One relative said that the home ‘made Mums birthday a very special time’. The manager has a very proactive approach to any concerns raised by residents and relatives and is keen to sort these out to the individuals’ satisfaction. Abberton Manor Nursing Home DS0000065842.V309378.R01.S.doc Version 5.2 Page 16 The home has up to date adult protection policies and procedures in place. Records show that new staff are issued with a copy of the local guidance as published by Social Services. Training records submitted show that nearly all the staff at the home, including ancillary staff, have received up to date training on this subject. Abberton Manor Nursing Home DS0000065842.V309378.R01.S.doc Version 5.2 Page 17 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 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well decorated and safe. The home is clean and hygienic. EVIDENCE: A partial tour of the premises was undertaken. Décor and maintenance levels were seen to be in good order and the home was seen to be clean, with no odours noted. Some repainting work has been carried out downstairs and more is planned, including the external paintwork. The condition of the furniture in both bedrooms and the communal areas was good and lighting in the home is satisfactory. A fire safety risk assessment was completed in July 2006 and some work has been carried out to reduce any noted risks. Records show that the fire safety systems are regularly tested and that staff fire drills are held. Certificates for Abberton Manor Nursing Home DS0000065842.V309378.R01.S.doc Version 5.2 Page 18 the maintenance of the fire safety systems were seen to be up to date. Training records show that all staff are up to date with their fire safety training. It was noted that portable oxygen cylinders were in use in resident’s rooms and warning signs should be displayed on the door, in the event of a fire. The home has up to date infection control policies and procedures in place and all staff are due to be trained on infection control matters in October 2006. There are no thermostatic control valves on the hot water system in the home and some resident outlets were tested and shown to be above the set level, at 46oc. The home needs to review the testing of this system in relation to the risk to residents and see if there is any action they can take to reduce the risk of scalding. Records show that monthly tests are being done and recorded well, but records also show that the water temperatures can be high. Abberton Manor Nursing Home DS0000065842.V309378.R01.S.doc Version 5.2 Page 19 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 good. This judgement has been made using available evidence including a visit to this service. The numbers and skill mix of staff currently meet the services users needs. Residents are in safe hands with staff at the home, many of who have NVQ qualifications. The home has sound recruitment policies and procedures, which it follows. Staff are trained and competent to meet the needs of residents. EVIDENCE: The home has a stable staff team and no agency staff are currently used at the home. The manager staffs the home in a flexible manner with residents needs affecting the way the home is managed. In the morning 1 qualified nurse and 6 care staff are on duty. In the afternoon/evening this reduces to 1 qualified nurse and 2 care staff with a twilight member of staff joining them in the evening. This can change in light of residents needs. At night 1 qualified nurse and 1 carer is on duty. Residents spoken to feel that enough staff are around to care for them and that if they use the buzzer system staff come promptly. Residents spoken to say that nothing is too much trouble for the staff and that they are a kind and caring team of people. Residents also said that they were good at helping to cheer you up and had time to stop and chat, which always helps. Abberton Manor Nursing Home DS0000065842.V309378.R01.S.doc Version 5.2 Page 20 The manager encourages care staff to undertake their NVQ qualifications and nearly 75 of the staff has achieved this qualification. Staff spoken to were pleased to have achieved this working at the home and felt that the course had helped with providing detailed knowledge and a better understanding of the responsibilities of a care assistant. The home has recruitment policies and procedures in place including equal opportunities. Staff files were inspected at random and found to be in good order with the required checks and documentation in place. A` checklist is recommended for the front of the file. Good interview records are maintained and it is recommended that a record be made to show that gaps in employment have been explored with the applicant. The manager has recently reviewed and extended the staff reference request form, making it a more comprehensive document. The manager has been completing a workforce-planning document. This includes consultation with all staff on a one to one basis and at meetings. The manager has been looking at specialised courses, relating to the needs of residents in the home and training trainers in order to provide some in-house training, such as manual handling. This work has helped to identify staff for NVQ training and plan the training programme for the team at the home. A new induction programme has been put into place and this is linked into Skills for Care. Records show evidence of staff induction but at the current time there are no completed new inductions available for inspection. Records show that staff are issued with Codes of Conduct and local POVA guidance. Training records show that staff are being trained and kept up to date with statutory training, including manual handling and fire safety. These records should be extended to include additional specialised training that the home provides for staff in the home. Records submitted show that the home has provided training on Communication with Younger Adults, Hickman Line Management, Wound Management, Challenging behaviour and the management of shunts. Records do not show how many staff attended these sessions. Staff spoken to at the home are content and enjoy working there because they feel that they are able to give a high standard of care to the residents. They also felt that the team are very resident focused and that resident choice is a key point. Abberton Manor Nursing Home DS0000065842.V309378.R01.S.doc Version 5.2 Page 21 Abberton Manor Nursing Home DS0000065842.V309378.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager is of good character, suitably qualified and fit to run the home. The home has a basic quality assurance programme in place, which could be developed further. Resident’s financial interests are safeguarded. The home has a staff supervision system in place that is developing. The health and safety of residents and staff is promoted. EVIDENCE: The manager is a qualified nurse with many years of clinical experience. Records show that she keeps herself updated and has commenced the Abberton Manor Nursing Home DS0000065842.V309378.R01.S.doc Version 5.2 Page 23 registered manager award, with 6 out of 10 units completed. Staff spoken to speak highly of her and feel that she is approachable, she listens to them and that she is firm but fair. Records show that staff meetings are held and a wide range of subjects are covered. It is not clear how many staff attend these meetings. The manager attends handover and also works a significant number of hands on shifts every month. The manager is developing the quality assurance systems in the home. This includes a managers review system whereby she goes around and speaks to residents and checks if they are satisfied with everything and that they understand their care. She actions any points raised that need attending to. This is recorded and records give a good account of discussions with residents. It is suggested that action points are dated when they have been addressed. Satisfaction and feedback questionnaires for residents and relatives are in place. These questionnaires are about to be sent out so no analysis was available for this inspection and this aspect of quality assurance was discussed with the manger. Further internal audits are recommended for care and care plans and staff files etc. This was discussed with the manager. In general the home does not hold personal monies on behalf of residents and encouraged families to take responsibility for this if required. Records were checked for the small amount of monies kept and these were in order with records of any deposits and spending. The home invoices residents 3 monthly for any extra items not covered in the standard fee, such as newspapers etc. Check resident’s monies and records.- do not hold personal monies as a rule. The manager has put a supervision and appraisal system in place. At the current time this mainly consists of shifts worked with staff and comments are recorded. Supervision mainly relates to practical work and although records of this are good they do not evidence that the supervision is a two way process. The manager is planning to develop the system further in line with the induction booklet, which will contain supervision sheets. Workforce planning has allowed staff to have a one to one discussion with the manager. The home has a health and safety policy in place. The manager has undertaken some safe working practice risk assessments but this area of work is still developing. Certificate for the safety and maintenance of fixtures and equipment in the home were inspected at random and found to be up to date and in order. The manager has appointed a member of staff to be responsible for COSHH in the home and will be attending a course in relation to this subject. The COSHH information in the home is currently being reviewed and updated. Accident records were reviewed as part of the case tracking and were seen to be completed well and contained sufficient detail. A regular review of accidents could form part of the quality assurance programme for the home. Abberton Manor Nursing Home DS0000065842.V309378.R01.S.doc Version 5.2 Page 24 Abberton Manor Nursing Home DS0000065842.V309378.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 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 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 X 3 Abberton Manor Nursing Home DS0000065842.V309378.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? N/a 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 OP1 Regulation 4 and 5 Requirement The registered person must make available an up to date Statement of Purpose and Service Users Guide. The registered person must ensure that all risk assessment are kept under review and where possible the resident or their relative are involved in the care planning process. The registered person must undertake a risk assessment to ensure that wherever possible risks are reduced to residents in relation to the hot water system at the home. Timescale for action 30/10/06 2 OP7 15 30/10/06 3 OP19 13 (4) 30/10/06 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 OP12 Good Practice Recommendations The registered person should link the activities records to the social care plan for individual residents. DS0000065842.V309378.R01.S.doc Version 5.2 Page 27 Abberton Manor Nursing Home 2 3 4 OP14 OP19 OP33 The registered person should set up a system for making inventories of resident’s belongings. The registered person should provide oxygen use warning signs where oxygen is used in the home. The registered person should continue to develop the quality assurance system in the home. Abberton Manor Nursing Home DS0000065842.V309378.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Abberton Manor Nursing Home DS0000065842.V309378.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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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