Inspection on 03/10/07 for Abbey House Nursing Home

This inspection was carried out on 3rd October 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 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

Abbey House Nursing Home 13/07/06

Abbey House Nursing Home 05/12/05

Abbey House Nursing Home 29/04/05

Abbey House Nursing Home 29/11/04

Abbey House Nursing Home 20/04/04

Abbey House Nursing Home 16/06/03

Similar services:

Flint House

St Vincents

The Cotswold Home

Fairways

Newbeech House

Winton House

Treloar College

Rush Court

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

CARE HOMES FOR OLDER PEOPLE Abbey House Nursing Home 2 Abbey Hill Netley Abbey Southampton Hampshire SO31 5FB Lead Inspector Anita Tengnah Unannounced Inspection 10:00 3 October 2007 rd 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 Abbey House Nursing Home DS0000011411.V347431.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. Abbey House Nursing Home DS0000011411.V347431.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbey House Nursing Home Address 2 Abbey Hill Netley Abbey Southampton Hampshire SO31 5FB 02380 454044 02380 456989 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) http:/www.abbeyhouse.org.uk/ Millennium Care Homes Limited Mrs Susan Ann Wilson Care Home 48 Category(ies) of Old age, not falling within any other category registration, with number (48), Physical disability (8), Physical disability of places over 65 years of age (48), Terminally ill (8), Terminally ill over 65 years of age (43) Abbey House Nursing Home DS0000011411.V347431.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. All service users in the PD category must be at least 50 years of age. Date of last inspection 13th July 2006 Brief Description of the Service: Abbey House is located on the edge of Netley village and approximately 3 miles from Southampton city centre. It is within easy reach of local amenities in the village including, churches, shops, pubs, restaurants and an attractive country park overlooking Southampton water. The home is set in well-maintained gardens including a sensory garden, close to the historic ruins of Netley Abbey. Originally a large Victorian house, the building has been converted and extended for use as a care home. Accommodation is provided on 3 floors and there are passenger lifts and stair lift that provide access to all areas of the home. Other facilities include a number of lounges, one of which is on the first floor a dining room, assisted baths, and a laundry service. The bedroom accommodation comprises thirtyfour single and seven shared rooms; twenty-seven of the single rooms have en suite facilities. The service has recently undergone an extension and provides six extra beds for intermediate care. The current fees charged are £529-£699 The fees do not include the cost of hairdressing, podiatry, toiletries, clothing or dry cleaning. Abbey House Nursing Home DS0000011411.V347431.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced visit to the service was undertaken as part of the inspection on the 3rd of October 2007. The process included a tour of the service where a number of the bedrooms, communal areas, kitchen, bathrooms, and laundry were viewed. As part of case tracking 6 staff and 8 service users views were sought and care records were looked at. Information gained from the Annual Quality assurance Assessment (AQAA) was also used and included in this report, as was information gathered by the commission since the last inspection to contribute in assessing judgements in this report. Positive comments were received from the service users regarding the care that they were receiving at the home. The commission received 3 comment cards from the service users and some contained input from their relatives. Care practices observed at the time of the visit showed that the staff and the service users had developed good relationships and care was provided in a respectful manner. What the service does well: What has improved since the last inspection? Abbey House Nursing Home DS0000011411.V347431.R01.S.doc Version 5.2 Page 6 The service has completed an extension and added on six beds with separate lounge/ diner that is used for intermediate care. There is an ongoing programme of refurbishment with regular renewal of equipments that include washing machines, hot trolley for meals and replacement of the conservatory. 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. The summary of this inspection report can be made available in other formats on request. Abbey House Nursing Home DS0000011411.V347431.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 Abbey House Nursing Home DS0000011411.V347431.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. 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. 3,6 The pre admission assessment process was detailed and contained very good information about the needs of people prior to moving into the service. The intermediate care service was well managed with dedicated staff to the satisfaction of people using it. EVIDENCE: The care records of two recently admitted service users were looked at as part of case tracking. Detailed pre admission assessments of needs were carried out and staff reported that this information is used to formulate their initial care plans on admission. Assessments of needs included dietary needs, likes and dislikes, manual handling assessments, skin integrity. Staff reported that the information was also sought from other healthcare professionals, as Abbey House Nursing Home DS0000011411.V347431.R01.S.doc Version 5.2 Page 9 appropriate in order to ensure that all care needs were identified. This included care manager’s assessment for those funded by the local authority. The manager discussed that the people are encouraged to visit the service prior to admission. One of the care plan seen indicated that the person did visit on two occasions and an assessment was carried out during the visit. The service has six beds where intermediate care is provided. There were four people using the service at the time of the visit. This service is provided in conjunction with the local primary care trust with dedicated staff that included occupational therapist and physiotherapist. The home has provided some staff dedicated to the intermediate care team and staff reported that this worked well. The people spoken were highly complimentary about the care that they were receiving. Comment was “this has helped me get better and the staff are very good”. Abbey House Nursing Home DS0000011411.V347431.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. 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. 7,8,9,10 The care plans and records of care given were good. Staff had clear information about the support that the service users required with their care. The health care needs and access to external agencies were well managed. The management of prescribed ointments and creams must be addressed in order to ensure that the service users are protected from risks of cross infection. Accurate records of all medication administered must be maintained. The service users are treated with respect and dignity and their right to privacy maintained at all times. EVIDENCE: Abbey House Nursing Home DS0000011411.V347431.R01.S.doc Version 5.2 Page 11 The care plans of 4 service users were seen as part of this visit to look at how the home plans to meet the needs of the service users. The care plans were detailed and contained information about the assessed needs of the service users and actions required by staff in order to meet them. These included assessments such as manual handling, dietary needs, continence, medication, and the psychological needs. There was evidence some evidence that the service users were involved in these assessments and should be further developed. Daily records of the care given were also available. The care plans were reviewed regularly to reflect any changes in the needs of the service users. Comments from the service users included “the staff are good and I am very happy here.” Another service user said that she had choices with her activities of daily living and commented, “I am treated with care and respect and I am not told what to do”. Another person spoken with said that she had lived at the home for a number of years and she preferred to spend her time in her room and the staff respected her choice. Comments for the questionnaires received included “my friend is well cared for and we are both happy with the home”. Records examined also indicated that a range of healthcare professionals that visited the home and arrangements were made for treatment for people using the service when it was necessary. The manager said that the GP visited on request and people spoken with said that received treatment from doctors, dieticians, when required and supported to attend hospital appointments. Equipments such as pressure relieving mattresses were available as identified through assessments. Care records seen for people with leg ulcers indicated that these were detailed with regular reviews and appropriate information about the types of dressings required. The home has a medication policy and procedure and staff were aware of these. The manager reported that the registered nurses were responsible for medication management. Regular update in medication was available. The home maintained records of medication received and discarded. A sample of the Medication Administration Record (MAR) sheets seen indicated that a record of prescribed medication administered was maintained. However there were some gaps in the records for some of the people. Staff must ensure that accurate records of medication administered are kept and appropriate coding is used to indicate reasons when these are not administered. There were records in place to indicate that some people were assessed for self- medication, however this must be developed to include all the people who are administering their own medication. The storage of the inhalers for one of the people must be looked into to ensure that this is managed safely. All medication was stored safely and included controlled drug. Records of controlled drugs seen were managed by registered nurses. Staff must ensure Abbey House Nursing Home DS0000011411.V347431.R01.S.doc Version 5.2 Page 12 that controlled medications belonging to people who are no longer at the service are disposed of safely according to the home’s policy. It was noted that a number of creams and ointments were in use that had been prescribed for other people. Some of the labels had been removed and were in use for other people. This was brought to the attention of the manager and staff and must be addressed immediately. The use of other people’s prescribed medication poses an infection control risk to them. The manager must ensure that prescribed ointments and creams must only be used for the named person and staff must follow procedures for returned medication once these are no longer needed. Further guidance is available in the Royal Pharmaceutical Guidelines. Comments cards received and 6 of the service users spoken with confirmed that the home provided a good service and they had autonomy and choice regarding the activities of daily living. Comments included ”I do as I please”. Another service user said “everyone of the staff is so kind” and that she “always felt safe”. Details of maintaining privacy and dignity were included I care plans. Screens were available inn all the shared bedrooms seen at the time of the visit and personal toiletries were well managed and separated in the shared rooms. Abbey House Nursing Home DS0000011411.V347431.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. 12,13,14,15 The social and recreational facilities for the service users are very good and well managed. The service users are supported to maintain links with the community and their family and friends. The service users autonomy and choices are respected in their activity of daily living. The meals are good and meet with the satisfaction of the service users. EVIDENCE: The home has a planned and varied programme of activities for the service users. The home employs an activity coordinator and also regular external entertainers visited the home. The activity coordinator reported that people Abbey House Nursing Home DS0000011411.V347431.R01.S.doc Version 5.2 Page 14 enjoyed the varied programme and some people participated more than others. On the day of the visit some of them were making apple struddle that they were going to have for tea. Two residents said that they were looking forward to this. Activities included games, music for health on alternate Thursdays, vitalise, sensory activities. The activity coordinator was planning activities for the Christmas season and including a trip to the theatre. A weekly diary of activities was maintained and included one-to-one activity for those who preferred not to join in with group activities. The home has an open visiting policy and it was evident from the record of visitors as kept by the home that there was no restriction on visiting. Comment received and three service users confirmed that they have autonomy to receive their visitors in private. Comment received included “we are always made welcome”. Comment cards received and people spoken with indicated that they were able to exercise choice and also maximise the control they had over their daily lives in the home. There were no restrictions to the time that they got up or went to bed. Independent advice such as accessing the advocacy service was displayed in the entrance hall. The home has a planned menu that is rotated on a four weekly basis. Comment cards received and the service users spoken with said that the meals were “ very good” that offered them variety and choices. The people spoken with stated that hot and cold drinks were available at all times. Comments included “excellent food” and “good choice “. All the service users were provided with a daily menu and the home had a hostess who supported them in choosing from the menu. There were two choices for the lunchtime meal including vegetarian choices. The chef reported that cakes are baked daily for afternoon tea and supper menu consisted of homemade soups, a baked dish and selection of sandwiches. Cooked breakfasts were available daily and staff reported that some of the people did choose a cooked breakfast on a regular basis. The chef was pro active and commented that food is an important factor in the people’s life and staff ensured that they have choices. Record of their likes and dislikes were maintained in their care plan. The kitchen was well managed and records of meals taken and food temperatures were maintained. Lunchtime meal was observed and appeared well presented, nourishing and well balanced. Meals included diabetics and pureed. Staff were observed to be available to offer support with meals as needed. The home also employs a hostess for the dining room which staff said was good as she supported them at mealtimes. Abbey House Nursing Home DS0000011411.V347431.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. 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. 16,18 The complaint process was well managed and the service users were confident that their complaints would be listened to. Staff had clear understanding of adult protection and ongoing training ensured that the service users were protected. EVIDENCE: The home has a complaint procedure that was provided to the people using the service and a copy was also displayed at the service. The people spoken with and comments cars received indicated that they would approach the manger if they had any concerns. Comments included ” this is a good home” and “ there is nothing to grumble about”. The home maintained a complaint log and record showed that there had been four complaints made to the service since the last visit. One of these was referred to as adult protection and investigated. It was evident from the record seen that the management took all concerns seriously and followed the home’s procedure in investigation them. Record of correspondence with the complainant was available at the service. The manager discussed that concerns about the management of the laundry were Abbey House Nursing Home DS0000011411.V347431.R01.S.doc Version 5.2 Page 16 raised at a recent service users/ relatives meeting and action plan was in place to resolve this. The record of the recent adult protection investigation was seen and the home did not receive minutes of the investigation and report of the outcome, although the manager reported that this had been resolved. Training in adult protection was available to staff and formed part of their induction. The home has in place the Hampshire Adult Protection procedure and staff were aware of the procedure to record and report all allegations of abuse. Abbey House Nursing Home DS0000011411.V347431.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. 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. 19,26 The home provides the service users with a high standard, clean and wellmaintained accommodation that meets their needs. The infection control procedures at the home are good and ensure that the service users are protected EVIDENCE: As part of the visit the inspector looked at a number of bedrooms, communal areas, bathrooms, laundry and kitchen. It was evident that the home has an ongoing programme of refurbishment. Accommodation is provided in a homely and well-maintained environment. The service has 3 shaft lifts that allow access to all parts of the building. Abbey House Nursing Home DS0000011411.V347431.R01.S.doc Version 5.2 Page 18 It was evident that people are encouraged to bring in items of personal belongings and supported to personalise their bedrooms. The bedrooms seen were highly individualised and reflected the people using the service’s personal tastes. Call bells were available in all bedrooms seen and accessible to them. The service had recently been extended with an addition of six beds for intermediate care. Further refurbishment planned for this month includes renovation of one the bathroom with overhead tracking for a hoist and changing one of the bathrooms into a walk in shower room accessible for wheelchair users. The ongoing refurbishment of the old part of the building should ensure that they are of the same high standard of the new build. The service has a laundry where all the laundry for people living there is undertaken internally. The laundry was fitted with two washing machines with sluicing programmes and two tumble dryers. Staff practices observed indicated that they we aware and followed infection control procedures. Gloves and aprons were available. Communal areas were fitted with disposable towels and liquid soaps. The provider stated that the flooring in the laundry was due for refurbishment. Abbey House Nursing Home DS0000011411.V347431.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. 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. 27,28,29,30 The staffing numbers are adequate to meet the present needs of the service users. The home has system in place to ensure that staff have the skills to deliver care safely. The recruitment process is very good. All checks are undertaken prior to employment to ensure the safety of the service users. There is a good training programme in place to ensure that staff are supported in their work. EVIDENCE: The home has a duty roster for nurses and carers and a separate roster for ancillary workers. A sample of the staff roster indicated that there are2 trained staff and 9 carers on the early shifts, and 2 trained staff and 7 carers on the afternoon shifts. The night staff included 1 trained staff and 5 carers. Staff and service users spoken with confirmed that they felt that there was adequate Abbey House Nursing Home DS0000011411.V347431.R01.S.doc Version 5.2 Page 20 staff to meet their needs. Comments from the service users were that there was “always” staff available when they needed assistance. The employment of an activity coordinator has further complemented the team and ensures that people using the service have one- to-one time spent with them. Comments from people included “the staff are busy but they always make time for you”. Information received from the AQAA showed that home has 12 carers who have completed NVQ2 and above. Five other carers were undertaking the course at present. Staff reported that the ancillary staff were also supported to achieve NVQ training. There was one housekeeping staff who was undertaking NVQ 2 at the time of the visit and the chef was aiming for NVQ at level 3. A sample of three recently recruited staff records were seen as part of case tracking. These indicated that all staff completed an application form and references are sought as part of the recruitment process. Application for Criminal Record Bureau (CRB) and POVA first checks are carried out. All staff had POVA first checks prior to starting work. The manager reported that staff started their induction while they were awaiting their CRB clearance and they were supervised. Records of these supervisions were not available. The manager confirmed that she would be addressing this. There is a thorough induction process in place and took up to twelve weeks to complete and records of these were available. Staff reported that the induction programme met with the Skills for Care format. The home has a good training programme in place to ensure that all staff have mandatory training in health and safety. The training manager kept a training matrix to help monitor training achieved and needs. Recent training included palliative care, wound dressing, infection control, dementia care and diet and nutrition assessment training. Training in prevention of abuse was available for all staff as a video and questionnaire on induction and then followed by further training. Staff spoken with said that training was good and having two staff members with train the trainer courses internally did help in the rolling out of the training programme. Abbey House Nursing Home DS0000011411.V347431.R01.S.doc Version 5.2 Page 21 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 good. This judgement has been made using available evidence including a visit to this service. 31,33,35,38 The home has a manager who is highly regarded and has clear lines of accountability for the service. The home does not manage any of the service users’ personal allowances or finances. The process of seeking the service users’ views for the intermediate care was well managed. Development of audits for the long- term care is needed. There is a satisfactory procedure in place to ensure the health and safety of the service users is promoted. EVIDENCE: Abbey House Nursing Home DS0000011411.V347431.R01.S.doc Version 5.2 Page 22 The home has a registered manager who is also a registered nurse with a number of years experience in the care of the elderly. The manager is in the process of completing her Registered Manager’s Award (RMA). The manager has an open and inclusive management style and demonstrated clear lines of accountability within the home. She undertook regular updates to maintain her skills and to upkeep her nursing registration. Service users spoke highly of the manager and said that she was “very good and listens”. Staff were also complimentary about the support and open door policy that the manager operated. It was evident from interaction observed that the staff and the service users had developed good relationships with each other. Comments from service users included “the staff are kind”. Another comment was “ staff have got time for you” and “they all try their best and I can do whatever I want and not told what to do”. The manager and the home administrator confirmed that the home did not manage any of the service users’ finances. Invoices are raised for all transactions such as hairdressing, chiropody and sent to their relatives/ advocates on a monthly basis. Staff reported that this worked well for them. A sample of questionnaires that had been devised for the intermediate care people was seen. This indicated a high level of satisfaction with the service that they were receiving. The home has a number of thank you letters and cards from relatives who were complimentary about the staff and the way that their loved ones had been cared for. There was no recent audit carried out of the permanent people living at the service and their relatives. The manager is aware of this and would be putting this in place. Information received from the AQAA indicated that there are regular reviews of policies and procedures to ensure that they meet current legislation/ guidelines. There is an ongoing programme for the servicing of fire equipment, hoists, wheelchairs, lift and emergency lighting. The chef reported that the environmental health officer visited last year and minor recommendation made at the visit had been completed. All substances that are hazardous to health were maintained safely. The home has a fire risk assessment and a fire plan was available in the entrance lobby. Abbey House Nursing Home DS0000011411.V347431.R01.S.doc Version 5.2 Page 23 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 4 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 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 3 X 3 X X 3 Abbey House Nursing Home DS0000011411.V347431.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No 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 17(1) (a) Schedule 3 13(2) Requirement An accurate record of all prescribed medications administered to people using the service must be maintained. The registered person must ensure prescribed ointments and creams are only be used for the named persons. Timescale for action 15/11/07 2 OP9 15/11/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Abbey House Nursing Home DS0000011411.V347431.R01.S.doc Version 5.2 Page 25 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 Abbey House Nursing Home DS0000011411.V347431.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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!