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Inspection on 05/12/05 for Abbey House Nursing Home

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

This inspection was carried out on 5th December 2005.

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.

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 standard of care in the home was good and was based on comprehensive assessments of the needs of both potential existing residents. These resulted in plans of care that ensured that residents received the individualised support and help that they required. Residents and relatives appreciated all the skills, competence and also the friendly and caring attitude of the staff. The home promoted the right of residents to make choices for themselves and exercise personal autonomy as far as was reasonably possible, including their participation in the civic process. Residents described the home`s bedroom accommodation positively terms and all bedrooms seen were well maintained and furnished and equipped. The home`s manager was experienced and both the home`s staff team and the residents valued her personal qualities and abilities. The staff team were well motivated. Management systems and procedures in the home worked well including, managing medication, dealing with complaints, staff training, record keeping and health and safety.

What has improved since the last inspection?

There were no matters of concern identified at the last inspection of the home on 29th April 2005.

What the care home could do better:

There were no matters of concern identified during this inspection visit.

CARE HOMES FOR OLDER PEOPLE Abbey House Nursing Home 2 Abbey Hill Netley Abbey Southampton Hampshire SO31 5FB Lead Inspector Tim Inkson Unannounced Inspection 5th December 2005 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Abbey House Nursing Home DS0000011411.V270928.R01.S.doc Version 5.0 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.V270928.R01.S.doc Version 5.0 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) Millennium Care Homes Limited Mrs Susan Ann Wilson Care Home 43 Category(ies) of Old age, not falling within any other category registration, with number (43), Physical disability (8), Physical disability of places over 65 years of age (43), Terminally ill (8), Terminally ill over 65 years of age (43) Abbey House Nursing Home DS0000011411.V270928.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. No more than 8 service users between 50 - 64 year of age in the categories PD and TI can be accommodated at any one time 29th April 2005 Date of last inspection 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 the village including, churches, shops, pubs, restaurants and an attractive country park overlooking Southampton water. The home is set in well maintained gardens, 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 three lounges, one of which is on the first floor a dining room and a conservatory, assisted baths, a laundry service and full board. The bedroom accommodation comprises twenty-nine single and seven shared rooms; twenty-one of the single rooms have en suite facilities. Abbey House Nursing Home DS0000011411.V270928.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the second of two inspections of the home that must be undertaken in the 12-month period beginning on 1st April 2005. It started at 09:10 hours and finished at 16:05 hours. The inspection procedure included viewing a sample of some bedrooms (9), an examination of documents and records, observation of staff practices where this was possible without being intrusive and discussion with residents (11), staff (5), and visiting relatives (4). At the time of the inspection the home was accommodating 43 residents and of these 11 were male and 32 were female and their ages ranged from 66 to 103 years. No resident was from a minority ethnic group. The home’s registered manager was available throughout the visit to provide assistance and information when required. What the service does well: What has improved since the last inspection? There were no matters of concern identified at the last inspection of the home on 29th April 2005. Abbey House Nursing Home DS0000011411.V270928.R01.S.doc Version 5.0 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. Abbey House Nursing Home DS0000011411.V270928.R01.S.doc Version 5.0 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.V270928.R01.S.doc Version 5.0 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): 3 The home’s admission procedures included good assessments of the needs of potential residents before they moved into the home to ensure that the home could provide the care and support that individuals required. EVIDENCE: The home had written policies and procedures concerned with the admission of new residents to the home and these referred to the importance of ascertaining the help required by potential residents before they moved into the home. The records of 3 residents were examined and these included copies of detailed assessments that the home had arranged of the needs of the individuals concerned. On this occasion as at the last inspection of the home on 29th April 2005 it was apparent from discussion with residents and the documents examined that the needs of potential residents were identified before the persons moved into the home. • “The under matron came to see me and to see if I was suitable to come here”. • “It was the matron that came to see Mum at Allington House before she moved here”. Abbey House Nursing Home DS0000011411.V270928.R01.S.doc Version 5.0 Page 9 It was also evident from the records examined that the home wrote to potential residents before they moved into the home informing them that the home could meet their assessed needs. The pre-admission assessments were complemented by more thorough and comprehensive assessments of a resident’s needs when they actually moved into the home. There was documentary evidence that assessments of residents needs were reviewed regularly and revised as necessary when an individual’s circumstances had changed. Abbey House Nursing Home DS0000011411.V270928.R01.S.doc Version 5.0 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 and 9 There were good plans of care in place that ensured that residents received the help and support that they needed. Good procedures and systems were also in place to ensure that medication was administered safely. EVIDENCE: On this occasion as at the last inspection of the home on 29th April 2005, a sample of the care plans of residents were examined (4). The documents were detailed and the plans were based on the assessments the home carried out in order to identify what help individuals needed (see pages 9 and 10). The plans set out clearly the actions staff had to take and what specialist equipment was needed to provide the support and assistance each person required. Observation and discussion with residents, relatives/representatives confirmed that individuals received the help they needed and that the equipment was in place as set out in their plans of care. There was evidence from both the documentation and discussion with residents that individuals and/or their representatives had been involved in developing the plans and agreed with the contents. • “They are good here, they listen to what I say, they wash me in bed if necessary and give me a shower they are very good”. • “Nothing is too much trouble for them” • “They look after me alright”. Abbey House Nursing Home DS0000011411.V270928.R01.S.doc Version 5.0 Page 11 • • • • • “I think they meet his needs, from what I have seen I believe the staff are skilled. I have learnt more about Dad’s condition since he has been here that I ever did from the hospital”. On the whole it is pretty good. They are very caring and their standards are high”. Someone helps me wash in the morning, it all depends on how I fee and I need help to go to bed”. “We have both been involved and I have seen and signed Mum’s care plan”. “I signed a care plan for my mother’s care”. All nursing and care staff spoken to were fully aware of the contents of the care plans that were sampled and the assistance that the individuals concerned required. The care plans documents included assessments of the potential risks to residents of among other things, pressure sores, malnutrition, and falls. Strategies for eliminating or reducing the risk of harm had been identified and implemented e.g. pressure-relieving aids were in place. There was documentary evidence that care plans were evaluated and reviewed regularly. Entries noted in care plans clearly indicated that the home promoted individualised care and the fundamental principles that underpin both social and health care e.g. • “X able to select her own care” • “Y has own teeth, offer her equipment to brush teeth after meals”. • “A prefers to remain in her own room for meals”. • “B is able to select her own clothing – offer clear and easy to understand explanations of all nursing interventions”. The home had written policies and procedures concerned with the management and administration of medication. A range of reference material about medication was readily available including a recent copy of the British National Formulary (BNF). Medication was kept in a locked room and also in 2 locked and secured medicine trolleys, and where required in a medical refrigerator. Controlled drugs were stored securely and in an appropriate metal locked cabinet. Medicines were dispensed from their original containers and the only staff responsible for the management and administration of medication were registered nurses. Records were kept of the ordering, receipt, administration and the disposal of medicines and these were accurate and up to date. The home had implemented new methods for the disposal of unwanted and unused medicines. This had arisen as a result of recent changes in the National Health Service contract for community pharmacists and to ensure compliance with legislation about the disposal of industrial waste. The home’s written medication procedures referred to above did not reflect this changed practice, but the home’s registered manager said that they would be Abbey House Nursing Home DS0000011411.V270928.R01.S.doc Version 5.0 Page 12 altered/amended to include the new practice that that had been implemented for disposing of unwanted and unused medicines. Abbey House Nursing Home DS0000011411.V270928.R01.S.doc Version 5.0 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): 14 The home had good procedures in place for ensuring residents could exercise self-determination. EVIDENCE: There was evidence from discussion with residents, relatives and also from documents and records kept by the home that individuals living in the home were able to exercise choice and also maximise the control they had over their daily lives in the home. The home’s Service Users Guide included details of a number of organisations that could provide independent advice, information or advocacy services for residents and their relatives. Although most residents had given the responsibility for managing their financial affairs to a relative/representative and expressed some relief at no longer having “to worry about such things” one resident said, “I deal with my own money. I have set up a standing order to pay my fees. I have my chequebook and if I want anything I can get it. I am quite capable”. Another resident clearly indicated that she deliberately chose to hand over the responsibility for the management of her financial affairs to someone else. • “My son has power of attorney, he is very good he can sign my cheques. I could do it myself if I wanted to”. The home’s Statement of Purpose included the following paragraph: Abbey House Nursing Home DS0000011411.V270928.R01.S.doc Version 5.0 Page 14 “We recognise the changes service users face when moving into a home. To minimise the impact of those changes we will promote the philosophy of a “family circle”. We will endeavour to retain as much privacy and dignity as possible by; helping service users personalise and equip their rooms as they wish”. Residents appreciated being able to bring personal items into the home including furniture and several individuals, including relatives spoken to indicated that this was important. The promotion of this right by the home included the opportunity for resident to bring their pets into the home with them and one resident had brought her cat with her. • “I think its lovely you can make it as lovely as you want”. • “The pictures on the wall and the television are mine”. • “We have brought Mum a few bits from home, pictures and her own chair”. A number of residents spoken to were aware that they could see records that the home kept about them. The home had written policies and procedures about “the control of records” and “access to personal files”. The former referred to the home’s obligations under data protection legislation and the latter to the right of residents to see their own records. Other comments from residents and relatives about the ability of individuals to exercise choice and control over their lives included the following: • “ I can have visitors whenever I want. There is a woman here who organises a nice church service and I support her by going as she goes to so much trouble to do it”. • “I have come in sometimes and Mum has been in bed, but it is only because she does not want to get up”. • “I get up early and go to bed late”. • “I don’t go downstairs, I eat my meals in my room – I am very lucky I can go to bed when I like”. Abbey House Nursing Home DS0000011411.V270928.R01.S.doc Version 5.0 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 17 The home had good procedures in place to ensure that residents concerns were addressed and to enable them to exercise their civic rights. EVIDENCE: The home had a written policy and procedures about how complaints could be made about the service that it provided. A copy was clearly displayed in the home’s entrance hall. All residents and relatives spoken to were confident about raising any concerns with staff or the home’s manager and most were fully aware of the procedure or where they could find a copy of it. The home kept records of complaints that detailed the issue, and set out any agreed action to remedy the matter and the outcome. There had been 3 complaints made to the home since the last inspection on 29th April 2005, and all had been responded to within the timescale set out in the home’s procedures and all had been resolved satisfactorily. No complaints had been made to the Commission for Social Care (CSCI) about the home in the last 12 months. Comments from residents and visitors about making complaints included the following: • “We would just go and tell them if we were unhappy, we would not hesitate”. • “If I was unhappy I would speak to anyone in the office”. • “I did speak to the owner about things that I was unhappy about”. • “I would talk to the matron if I was unhappy”. Abbey House Nursing Home DS0000011411.V270928.R01.S.doc Version 5.0 Page 16 The home’s registered manager said that residents were registered by the home with the local council and their details were on the electoral roll. Also that residents were consulted about whether they wanted to vote by post. Residents spoken to confirmed that they were able to vote in elections and participate in the civic process. • “I found myself with a vote in the conservative party leadership contest and I voted the other day”. • “I have a postal vote” • “I don’t bother to vote because each lot is as bad as the other, but I could vote if I wanted to”. Abbey House Nursing Home DS0000011411.V270928.R01.S.doc Version 5.0 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): 24 and 25 The home’s bedrooms accommodation was well maintained, furnished and equipped for service users safety and specific needs. EVIDENCE: All residents and relatives spoken to expressed contentment with the condition of the bedroom accommodation including the furniture and equipment in them. Comments from residents about these matters included: • “I like this room, the staff complain that it is the smallest room but I don’t want a huge room. I think I picked the warmest in the place, sometimes it is too hot but most of the time it is just right. I like the window open. The lighting is excellent”. • “It’s not bad. He is happy and he can have his window open to keep cool” • “It’s nice and it has everything that she needs”. • “It’s not a bad little room. They keep it up together and I have seen them shampooing carpets. The room is warm enough”. Bedrooms viewed varied in size and configuration but were furnished and equipped as expected by Standard 24 of the National Minimum Standards for Abbey House Nursing Home DS0000011411.V270928.R01.S.doc Version 5.0 Page 18 care Homes for Older People. They were; fitted with carpets; doors were fitted with suitable locks; naturally ventilated and heated by radiators that were covered with guards to prevent residents from the risk of burns. All shared bedrooms viewed were provided with screening to provide privacy. The nurse call system was tested in one room. It was working and staff responded very quickly when it was activated. The temperature of the hot water was tested in 3 bedrooms and it was “comfortable” and records were seen of regular testing of the temperature of water at hot outlets throughout the home and it was being delivered at around 43°C. Abbey House Nursing Home DS0000011411.V270928.R01.S.doc Version 5.0 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): 28 and 30 The home’s commitment to and staff training and development procedures were good. They ensured that staff had opportunities to acquire relevant skills and competence and could be deployed with an appropriate skill mix in order to meet the needs of the residents. EVIDENCE: There were 26 health care assistants employed to work in the home at the time of the inspection and of these 8 (31 ) had obtained a National Vocational Qualification (NVQ) to at least level 2 in care or its equivalent. The home’s registered manager was acutely aware of the expectation that at least 50 of care staff should be qualified to at least NVQ level 2. There was some discussion about training and among other things how the home could ensure that more staff could have their competence formally assessed to enable them to obtain a relevant qualification. Discussion with staff and the home’s manager indicated that both the home and individuals staff members were committed to staff training and professional development. Recently at one time there had been 6 care staff pursuing NVQ qualifications but 4 had resigned and left their employment for various reasons before they had completed their training. Others had not completed their training because of problems with training providers that had gone out of business. The home’s manager said that she was meeting with the home’s owners 2 days after the inspection visit and she was submitting a proposal for the appointment of a training co-ordinator for the home. The person would be an NVQ assessor, facilitate training, keep all necessary records and liaise with Abbey House Nursing Home DS0000011411.V270928.R01.S.doc Version 5.0 Page 20 training providers. She subsequently confirmed that her proposal had been accepted. All new care staff completed an induction-training programme that satisfied the requirements of “Skills for Care”. (The sector training organisation that replaced the “Training Organisation for Personal Social Services” [TOPSS] in April 2005). Staff training needs were identified through appraisals and individual supervision sessions and all staff spoken to indicated that they appreciated the opportunity to increase their knowledge and skills. All staff spoken to had attended training courses relevant to the care the home provided and many had attended or were pursuing training courses that were essential elements of NVQ awards e.g. infection control. Staff spoken to were enthusiastic about their work and expressed positive views about the home and training. • “I started in October, I worked in another care home. I am doing my induction now and hope to finish in the next couple of weeks. It has included how to approach people when doing personal care and also peoples’ rights and choices. It is heaven working here. Where I was before I spent more time in the kitchen than looking after people, but here I am using my training”. • “I attend all the training and I have done manual handling. I am currently doing infection control. It is difficult. My induction training took some time and I asked about things if I was not sure”. • “I am ding NVQ 3 and I also do the normal things like manual handling and fire safety. We have annual appraisals and discuss training. I have done care of the dying and attended a study day at the local hospice and we also have a training day on dementia care on Wednesday”. • “I go on as many study days as I can. I also use the Internet and read a lot. I liaise with other healthcare professionals and the local hospice and they arrange training days for all staff here, registered nurses and care staff”. • “I love it here, I am able to compare it with another home where I worked in Glastonbury”. All residents and relatives spoken to expressed confidence in the abilities of the home’s staff team. • “The staff here as good as anywhere, they are so kind and do whatever I ask and I think I am a bit of a trial sometimes”. • “We think its top notch. Its alright for mothers’ and cats” • “We are relaxed because we know that Mum is being looked after properly”. • “They are all very friendly here, they are on the ball, and the matron is on the ball”. Abbey House Nursing Home DS0000011411.V270928.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 37 and 38 The home’s manager had the experience and skills necessary to run the home effectively. Systems for keeping records and managing health and safety in the home were good ensuring that residents’ welfare and interests were safeguarded. EVIDENCE: The registered manager was a registered nurse and had been responsible for the day-to-day functioning of Abbey House for some 4 years. Prior to working at the home she had been the manager of another home proving nursing care that was owned by a large national corporate provider. During the last 12 months she had kept up to date with developments, maintaining and improving her knowledge and skills by attending at least 4 relevant seminars/workshops arranged through trade associations to which the home belonged. She was hoping to complete the registered managers award within the next 12 months. Staff, residents and relatives spoken to indicated that they had confidence in the manager’s abilities and in particular her clinical knowledge and skills. Abbey House Nursing Home DS0000011411.V270928.R01.S.doc Version 5.0 Page 22 Residents also thought highly of the manager and one said: • “The matron is an extraordinarily nice person”. One relative commented: • “…..the matron is on the ball” The following statutorily required records were among the documents examined during the inspection visit and at the time of the inspection they were all accurate and up to date: • • • • • • • • • Assessments and care plans for residents and related records. Statement of Purpose Service Users Guide Medication Fire safety including tests of equipment and drills and staff training Staff Visitors to the home Accidents Complaints There was evidence from both discussions and records that all staff working in the home had received regular training in health and safety subjects that were relevant to their role in the home. These included first aid, fire safety, food hygiene, moving and handling, infection control and control of substances hazardous to health. Records also indicated that systems and equipment in the home were tested and serviced at intervals and with the frequencies either required according to relevant regulations or good practice. These included: • Fire safety equipment • Electrical wiring • Gas appliances and central heating • Portable electrical appliances • Hoists and slings • Lifts • Hot water systems –(tested for temperature and the presence of legionella). Abbey House Nursing Home DS0000011411.V270928.R01.S.doc Version 5.0 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 X X X X X X 3 3 X STAFFING Standard No Score 27 X 28 2 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X X 3 3 Abbey House Nursing Home DS0000011411.V270928.R01.S.doc Version 5.0 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. 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. Refer to Standard Good Practice Recommendations Abbey House Nursing Home DS0000011411.V270928.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 House Nursing Home DS0000011411.V270928.R01.S.doc Version 5.0 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!