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Inspection on 09/09/05 for Abbey Court Nursing Home

Also see our care home review for Abbey Court Nursing Home for more information

This inspection was carried out on 9th September 2005.

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home provides a good standard of nursing and residential care in a homely atmosphere. Staff interaction with residents was very good and there was a high level of satisfaction from the residents. The home has a holistic approach to care and does particularly well in the care of people with a mental illness. Staff training continues to be given a high priority. To support the above, very positive comments were made to the inspector by residents and visitors/relatives. The inspector observed the care being delivered and the good interaction between staff and residents. A discussion took place with care staff on duty, which gave a good account of how they were meeting the needs of the residents. Their documentation of care delivery was seen as good and meaningful.

What has improved since the last inspection?

Staff training has continued to be given a high priority. A planned maintenance programme has been introduced, and the redecoration programme has continued. The visitor`s/meeting room has been created. The two previous recommendations have been satisfactorily addressed.

What the care home could do better:

No requirements or recommendations were raised during this inspection. It was agreed that there was little that the home could improve upon, particularly within the current financial restraints of Local Authority funding. The internal redecoration and minor upgrading work is ongoing and budgets have been allocated.

CARE HOMES FOR OLDER PEOPLE Abbey Court Nursing Home Heath Way Heath Hayes Cannock Staffordshire WS12 5XP Lead Inspector Dave Cowser Unannounced 9 September 2005 9:30 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. Abbey Court Nursing Home E51-E09 S22389 Abbey Court V246275 090905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Abbey Court Nursing Home Address Heath Way Heath Hayes Cannock Staffordshire WS12 5XP 01543 277358 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) Restful Homes (Cannock) Ltd Miss Sarah Edwards CRH 117 Category(ies) of DE- 59 registration, with number MD - 10 of places MD(E) - 25 OP - 80 PD - 58 PD(E) - 35 Abbey Court Nursing Home E51-E09 S22389 Abbey Court V246275 090905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: DE Minimum age 60 years MD Minimum age 55 years PD Minimum age 55 years Date of last inspection 27 October 2004 Brief Description of the Service: Abbey Court is a purpose-built care home, providing nursing and residential care, located within a residential area on the outskirts of Cannock. The home can accommodate up to 117 service users in the following categories; Dementia care (59), Mental disorder, excluding learning disability or dementia (10), Mental disorder, excluding learning disability or dementia- over 65 years of age (25), Old age not falling in any other category (80), Physical disability (58), Physical disability over 65years of age (35). There are a total of 13 lounges available to the service users including a specific smoking lounge. There are four dining rooms and ample facilities in the home including two hairdressing salons. The home has an enclosed garden with a suitable patio area. All areas of the home have access via the stairs and/or passenger lift. Service users requiring general care (nursing and residential) are catered for on the ground floor of the home and those service users with mental health needs (nursing and residential care) were catered for on the first floor. The registered care manager is in charge of the home. Care is provided by first level nurses, both RGN and RMN, and teams of care assistants. Local GP practices and a pharmacist service the home. Community nurses, health service proffessionals and NHS facilities are accessed as and when required. Abbey Court Nursing Home E51-E09 S22389 Abbey Court V246275 090905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This routine unannounced inspection was made on the 9 September 2005 @ 09.30hrs. The inspection was undertaken using the National Minimum Standards for Older People as a reference. Two inspectors undertook the inspection and the total time spent for the inspection, including pre and fieldwork, amounted to 18hrs. The registered care manager (RGN) was in charge of the home; accompanied by two RGN’s, an RMN and EN(M), and sixteen care assistants. The ancillary staff on duty included; domestic workers, one-maintenance person, catering staff and a laundry person. The home appeared to manage after, and the homeowner was present throughout, and the administrative support person was also on duty. These staffing levels were adequate to meet the needs of current 115 residents in the home. The total of 115 residents included 96 nursing patients and 19 with personal needs. Of the 96 patients 43 had physical needs and 53 had psychological needs. Of the 19 residents 15 had needs associated with old age and 4 had a dementia related condition. The inspection included the following elements; a tour of the building, observation and inspection of records relating to provision of care, discussions with six residents and six visitors, discussions with staff members on duty, observation and sampling of other services provided, such as catering and laundry, and an inspection of the managerial aspects such as staffing issues, quality assurance and health & safety. Since the last inspection on 27 October 2004; there had been no changes to the running of the home. Nine complaints had been received during this eleven-month period, of which; 6 were currently being processed by CSCI, 1 had not been upheld, and 2 had been partly upheld. Additional visits to the home had been necessitated in order to investigate these complaints. During the past 12 months there had been 63 deaths recorded. Currently 9 residents had a pressure area (6 hospital acquired prior to admission to this home). This aspect was discussed and assurances were given that these pressure areas were all healing and the correct treatment was being delivered. No incidents or reports of abuse of any kind had been received and policies and procedures seen covered these issues. Since the last inspection 6 residents had attended an A&E department due to an accident and had sustained a fracture. It was evident that aspects of care had been well addressed, with residents able to choose the home following an assessment and invitation to visit the home. Service user plans had been well written, based on the community care Abbey Court Nursing Home E51-E09 S22389 Abbey Court V246275 090905 Stage 4.doc Version 1.40 Page 6 plans completed by social workers. Health, personal and social care needs had been met and well documented. Privacy, dignity and choice aspects for residents were being upheld. The home was fit for purpose and provided a safe environment for the residents and staff. A homely atmosphere had been created, and the premises were clean, warm and tidy. Adequate areas for residents were provided including; communal spaces, dining/activity space, bathing/toilet facilities, and bedrooms. Services and facilities, including catering and laundry, were well provided. Health and safety aspects had been given a high priority and no shortfalls were noted. Staffing levels and skill mix had been adequate to meet the assessed needs of the existing residents/patients. Recruitment and retention of staff aspects were good with little staff turnover. Staff training had been given a high priority, with induction training being followed by NVQ training, and staff had received regular supervision. The home had achieved 78 care assistants with NVQ level 2 qualification or above. The home appeared to be managed well by a nursing care manager, and the homeowner. General management aspects were good with quality assurance taking place. Records had been correctly filed and stored. Assurances were given regarding the positive financial viability of the home, and that the company adopted suitable accounting/business procedures. The two recommendations made on the last report had been addressed, and no requirements or recommendations were made during this visit. What the service does well: The home provides a good standard of nursing and residential care in a homely atmosphere. Staff interaction with residents was very good and there was a high level of satisfaction from the residents. The home has a holistic approach to care and does particularly well in the care of people with a mental illness. Staff training continues to be given a high priority. To support the above, very positive comments were made to the inspector by residents and visitors/relatives. The inspector observed the care being delivered and the good interaction between staff and residents. A discussion took place with care staff on duty, which gave a good account of how they were meeting the needs of the residents. Their documentation of care delivery was seen as good and meaningful. Abbey Court Nursing Home E51-E09 S22389 Abbey Court V246275 090905 Stage 4.doc Version 1.40 Page 7 What has improved since the last inspection? 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. Abbey Court Nursing Home E51-E09 S22389 Abbey Court V246275 090905 Stage 4.doc Version 1.40 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Abbey Court Nursing Home E51-E09 S22389 Abbey Court V246275 090905 Stage 4.doc Version 1.40 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 Individual health, personal and social cares needs had been established and were being met by staff, which individually and collectively had the necessary skills and experience. Prior to admission all service users had the opportunity to visit the home, and agree terms and conditions of stay. The above had ensured that the home had the ability to meet the individual needs of service users. EVIDENCE: The documentation seen, and a discussion with residents/representatives, evidenced that residents had been assessed prior to admission and they had been enabled to make a choice about the home. All involved had the opportunity to visit the home prior to choosing an admission. Several residents spoken to had visited the home, and had a meal prior to deciding to stay, and this was seen documented within the care plans. The community care plans provided by the social worker, as part of the individual needs assessment process, were seen within the service user plans. Residents asked confirmed that they had been fully involved and were in agreement with the assessments. The records seen and a discussion with the staff evidenced that nursing and care staff, individually and collectively, had Abbey Court Nursing Home E51-E09 S22389 Abbey Court V246275 090905 Stage 4.doc Version 1.40 Page 10 the necessary experience and skills to meet the assessed needs of the current service users. Abbey Court Nursing Home E51-E09 S22389 Abbey Court V246275 090905 Stage 4.doc Version 1.40 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10 Service users had comprehensive individual care plans, which set out their individual health, personal and social care needs. Service users’ had access to healthcare services to meet their individuals’ needs. There was a safe system for the receipt, storage, administration and disposal of medicines. Respect, privacy and dignity were afforded to residents. Staff had handled deaths with care, sensitivity and respect. All the above had ensured that service users identified needs were being met. EVIDENCE: Each service user had a named nurse who was responsible for the individual service users’ care and relevant documentation. Activities of Daily living were documented and there was evidence that they were reviewed monthly along with the relevant individual risk assessments. Staff spoken to was aware of the need to assess individuals prior to admission to ensure the individuals needs could be met in the home and that they were in the correct registration category. Service users spoken to at the visit were aware that they had a care plan, and where possible they or their relative signed to agree its content. This process is ongoing with the use of the newly introduced paper work. Abbey Court Nursing Home E51-E09 S22389 Abbey Court V246275 090905 Stage 4.doc Version 1.40 Page 12 Suitably trained nurses assess service users, with regard to personal and oral hygiene, including foot care and physical activity, and this was seen documented. There was evidence that relevant assessments are recorded for nutritional needs, prevention of falls, promotion of continence and moving and handling needs. Individual skin integrity is also assessed and monitored, as is the individuals’ psychological state. Currently 9 residents had a pressure area (6 hospital acquired prior to admission to this home). This aspect was discussed and assurances were given that these pressure areas were all healing and the correct treatment was being delivered. Doctors and Nurse Specialist visits were recorded in the individual care records as necessary. Access to NHS services is available as required by the individuals and arrangements are made to transport and escort the service users to their appointments. There was evidence of appropriate equipment being used in the home and the staff where all trained and competent to use it. Documentation was neat, informative and reflected the current needs of the individual service users seen by the inspector on the day. Robust procedures were evident in the home with regard to appropriate administration of medicines. The dispensing pharmacy and the manager complete regular quality audits to ensure procedures and practices are being maintained. Only trained nurses administer medication in the home. Care staff was aware to constantly observe for side effects or the need for analgesia. It was evident throughout the inspection that residents were treated with respect and afforded privacy and dignity. The single bedrooms with en-suite facilities assisted in upholding these values. Service users have access to a private telephone room; however there is also access to a hand held telephone for the less able. Visitors are welcome in the home at any reasonable time, and a good interaction between the staff and visitors was noted. The inspectors spoke to several residents and visitors, who all felt the staff were well trained and recognised the need to promote privacy and dignity. Policies and procedures for death and dying were available and the care staff asked was all familiar with them. Letters were seen from relatives expressing gratitude, and thanking the staff for their involvement during their loss of a loved one. The manager is trained in palliative/terminal care and takes a strong interest in the care being provided. Abbey Court Nursing Home E51-E09 S22389 Abbey Court V246275 090905 Stage 4.doc Version 1.40 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 standard(s) 12,13,14,15 Service users can expect to experience a life style that matches their expectations and preferences whilst in the home. Social, cultural, religious and recreational needs and interests were being promoted. Contact had been maintained with family and friends of residents. Service users can exercise choice and some control of their lives. Catering aspects were good, ensuring that residents receive a balanced and nutritious diet, to meet their expectations. Discreet assistance is given to service users who are less able by staff who are knowledgeable on their likes and dislikes. EVIDENCE: A full time activity coordinator is employed at the home and she promotes and supports the individual service user to achieve their individual preferences. This information is kept in individual records and a diary. Leisure and social activities are arranged and displayed on a weekly sheet to advertise morning and afternoon, as well as future events. Service users spoken to said they enjoyed the activities and felt it was just about the right amount. They said they enjoyed the occasional trip out but not too many. Approximately 900 visitors enter the home in a week, and they sign in and out in reception. Visiting is encouraged at any reasonable time of the day. A visiting policy is available for relatives and representatives to see. Service users may receive their visitors in private in their own bedroom or in one of the many lounges available. Abbey Court Nursing Home E51-E09 S22389 Abbey Court V246275 090905 Stage 4.doc Version 1.40 Page 14 Service users are encouraged to bring to the home their individual possessions in which to personalise their bedroom. Advocacy services are available as required. The dining rooms are tastefully decorated and tables were dressed with cloths and individual menus were displayed. Three full meals are served on a daily basis along with hot and cold drinks and snacks if desired. Specialist and therapeutic diets are catered for and dieticians are consulted as required. Discreet assistance is given to service users who are less able and this was performed in a compassionate manner. Dietary needs were recorded in the care records along with individual likes and dislikes. Service users when asked said they looked forward to their meal times, as the food was tasty and varied. The inspectors observed the mid-day meal, which was well presented and met all requirements. Abbey Court Nursing Home E51-E09 S22389 Abbey Court V246275 090905 Stage 4.doc Version 1.40 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 standard(s) 16,17,18 Complaints or grumbles are listened to and resolved. The home policies, procedures and staff training, protected residents from aspects of abuse. Service users legal rights are protected. EVIDENCE: An examination of the complaints book, the relevant policy and procedure documentation, and a discussion with staff and residents, evidenced that complaints and grumbles were listened to and dealt with in the correct manner. Since the last inspection, eleven months ago, nine complaints had been recorded or brought to the attention of this commission. Three of these were found to be ‘not upheld’, and the remaining six are currently being investigated and are awaiting finalization by CSCI. Many ‘thank you’ and complimentary cards were seen from appreciative relatives. No incidents of neglect or abuse of any kind has been reported. The policy documentation seen, and a discussion with staff confirmed that residents are protected from all forms of abuse. Since the last inspection 6 residents had attended an A&E department due to an accident and had sustained a fracture. Documentation seen evidenced that the above issues had been discussed at length during staff induction, training and on-going supervision Abbey Court Nursing Home E51-E09 S22389 Abbey Court V246275 090905 Stage 4.doc Version 1.40 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,26 The premises were fit for purpose, with more than adequate personal and communal facilities provided. The home provided a safe and well-maintained environment for residents. The home was clean, warm and tidy, and had a very comfortable atmosphere. Hygiene matters and cross infection issues were well addressed. The home provided 100 single room occupancy, which met resident’s expectations. Adequate ancillary staff were employed which ensured that the hotel services aspects were well addressed. EVIDENCE: A tour of the premises, and a check on the maintenance documentation, verified that the premises were fit for purpose, clean warm and tidy. The duty rosters evidenced that adequate ancillary staff were employed. Staff when asked told the inspector of their knowledge on infection control, and showed him the relevant documentation. Adequate hand washing facilities were available throughout the home. The laundry and sluice facilities were seen to be fully compliant. Abbey Court Nursing Home E51-E09 S22389 Abbey Court V246275 090905 Stage 4.doc Version 1.40 Page 17 The records evidence that maintenance of the premises was being given a high priority. Hot water temperature checks, and emergency lighting/fire alarm tests were seen up to date and correct. The internal redecoration and minor upgrading is ongoing and budgets have been allocated. There are no outstanding issues known from the Environmental Health or the Fire Prevention departments. A tour of the building evidenced that all 117 beds are in single rooms (100 single bedroom occupancy). Residents spoken to were very happy and settled in their rooms. During the inspection the inspectors commented on the very homely appearance of the bedrooms, which had been individualized. Abbey Court Nursing Home E51-E09 S22389 Abbey Court V246275 090905 Stage 4.doc Version 1.40 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) 27,28,29,30 The assessed needs of service users had been met by an adequate number of suitably trained staff. Recruitment procedures for staff had been correctly addressed, which had contributed to the protection of service users. Staff training had been given a high priority, and 78 had achieved level 2 NVQ qualifications, which had contributed to the high standard of care being delivered. Abbey Court Nursing Home E51-E09 S22389 Abbey Court V246275 090905 Stage 4.doc Version 1.40 Page 19 EVIDENCE: The duty rosters seen, and a discussion with the care manager and the staff, evidenced that adequate numbers of staff had been on duty to meet the needs of the existing service users. The following care staff had been on duty or exceeded for the 115 residents; a.m. 2 RGN & 2 RMN 16 Care assistants ( Care manager RGN for 5 days), p.m. 1RGN & 1RMN 14 Care assistants. nights 1RGN & 1 RMN 8 Care assistant. The care manager and her deputy also provide an on-call system. In addition to the above adequate ancillary staff had been rostered on duty throughout the week. Six residents asked stated that staff were available when requested, and that the staff were capable. The records seen evidenced that in addition to first level nurses the home had 78 of care assistants trained to NVQ level 2 or above. The home recruitment policy, procedures and documentation were examined and recruitment issues had been handled correctly. Staff had been subject to POVA/CRB comprehensive checks, and these were seen recorded. Staff asked stated that they had job descriptions and contracts of employment. Training had been given a high priority and the training records of individuals were seen. The records evidenced that both trained nurses and care assistants had benefited from ‘in house’ and external training which had covered the needs of the registered client group. Staff told the inspector that they had been afforded the time off and encouraged to study. Abbey Court Nursing Home E51-E09 S22389 Abbey Court V246275 090905 Stage 4.doc Version 1.40 Page 20 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) 33,35,38 The home appeared to be well managed and quality assurance was in place. Financial aspects were correctly addressed and recorded with safeguards to residents. Health and safety issues had been given a high priority and managed well. All the above had contributed to the protection of service users. EVIDENCE: From observations made, discussion with service users, and discussions with the manager and staff, it was evident that the home was being run in the interests of service users. Quality assurance, including feedback from residents and their representatives, was seen documented. Documentation seen evidenced that the views of visiting professionals had also been established, and included in the review process. A check on the records and a discussion with both residents and representatives evidenced that all service users had the opportunity to handle their own finances and all residents and families had chosen to do so. Day to Abbey Court Nursing Home E51-E09 S22389 Abbey Court V246275 090905 Stage 4.doc Version 1.40 Page 21 day monies of residents were checked and money held reconciled with the ledger. Inventories of valuables and belongings brought into the home were seen recorded. No contraventions of health and safety issues were noted during this inspection, including a tour of the home. The comprehensive documentation seen for checks and examination of plant and equipment was all correct and up to date. The manager and staff spoken to confirmed that health and safety issues are given a high priority. Abbey Court Nursing Home E51-E09 S22389 Abbey Court V246275 090905 Stage 4.doc Version 1.40 Page 22 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 4 x x x HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 4 10 4 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION 4 x x x x x x 3 STAFFING Standard No Score 27 3 28 4 29 x 30 4 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 3 x 3 x x 4 Abbey Court Nursing Home E51-E09 S22389 Abbey Court V246275 090905 Stage 4.doc Version 1.40 Page 23 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. Standard Regulation Requirement Timescale for action 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 Good Practice Recommendations Abbey Court Nursing Home E51-E09 S22389 Abbey Court V246275 090905 Stage 4.doc Version 1.40 Page 24 Commission for Social Care Inspection Stafford - Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 Abbey Court Nursing Home E51-E09 S22389 Abbey Court V246275 090905 Stage 4.doc Version 1.40 Page 25 - 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. You have been warned!