Inspection on 16/05/06 for Abbeycroft Care and Nursing Home

This inspection was carried out on 16th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Abbeycroft Care and Nursing Home 05/07/07

Abbeycroft Care and Nursing Home 30/11/05

Abbeycroft Care and Nursing Home 07/07/05

Abbeycroft Care and Nursing Home 03/02/05

Abbeycroft Care and Nursing Home 27/04/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Abbeycroft Care and Nursing Home Burnley Road Loveclough Rossendale Lancashire BB4 8QL Lead Inspector Mr Graham Oldham Key Unannounced Inspection 16th May 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Abbeycroft Care and Nursing Home DS0000056843.V289613.R01.S.doc Version 5.1 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. Abbeycroft Care and Nursing Home DS0000056843.V289613.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Abbeycroft Care and Nursing Home Address Burnley Road Loveclough Rossendale Lancashire BB4 8QL 01706 225582 01706 213636 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) Regency Healthcare Limited Care Home 37 Category(ies) of Old age, not falling within any other category registration, with number (37), Physical disability (37) of places Abbeycroft Care and Nursing Home DS0000056843.V289613.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 37 service users to include up to 37 service users requiring nursing care who fall into the category of OP (Over 65 years) Up to 37 service users requiring nursing care who fall into the category of PD(E) Date of last inspection 30th November 2005 Brief Description of the Service: Abbeycroft is registered to provide personal and nursing care for up to 37 older people. Nursing and residential care is provided. The home is purpose built within its own grounds. The home is located in a semi-rural position close to a local bus route with easy access to Burnley or Rawtenstall. There are extensive views over the countryside. There is a car park to the front of the property and the gardens are accessible to residents. There was a statement of purpose and service user guide available for residents to help with their choice of home. A statement of purpose and service users guide is available for residents or their families to be informed of the facilities and services the home provides. Accommodation is provided in single and twin-bedded rooms on three floors. Communal space is available on each floor. There is a dedicated smoking area and a new conservatory was nearing completion. The fees for Abbeycroft range from £315 - £452. Extras residents or their families have to pay include hairdressing, newspapers or periodicals and outings. Abbeycroft Care and Nursing Home DS0000056843.V289613.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 16th May 2006. Much of the information gained was obtained from talking to residents and staff members. The views of residents were obtained on a variety of topics. Three residents were case tracked. Case tracking gave the inspector an overall view of the specific care for the individual resident by checking the plans of care, other documentation and talking to residents and staff. Two staff members, two directors of the company were talked to about care, training and management issues. Two visitors commented upon their viewpoints. Some of the views have been reported collectively with specific comments contained within the body of the report. The inspector took detailed notes during the inspection, which have been retained as evidence. Staff were directly and indirectly observed carrying out their tasks and interacting with residents. Paperwork examined included plans of care, assessment documentation, policies and procedures or documents relevant to each standard. A tour of the building was conducted. Three resident questionnaires and five visitor questionnaires were returned to the CSCI prior to completing the report. What the service does well: Five comment cards retuned to the CSCI from relatives all said they were kept informed of important matters. Four said they were informed about care issues. The comment from the one relative/friend who was not informed of care issues said, “its not relevant to me”. Family and friends were kept well informed of any issues to keep them up to date with the care of their relative. Staff were observed to treat residents with privacy and dignity when delivering personal care. One resident case tracked said, “They treat me very privately. I am dependent upon them for nearly everything. We have a laugh and joke all the time. Staff are first rate”. One visitor said, “They treat care very privately. They even ask me to leave sometimes. My wife was always a very private person”. Staff were careful to protect the privacy and dignity of residents to ensure they were comfortable with personal care. Five comment cards returned from relatives said staff and owners welcomed them into the home and visits may be taken in private. One resident case tracked said, “I get visitors but they are all dying off. My nephew visits regularly and phones every day. I speak to his two daughters whose photographs are there on the wall”. One visitor said, “I visit every day and the staff are very friendly”. Another visitor said, “Staff are welcoming to me and brilliant to my wife”. Staff were welcoming and encouraged visitors. Residents described their choices and were able to retain some independence. Abbeycroft Care and Nursing Home DS0000056843.V289613.R01.S.doc Version 5.1 Page 6 Recruitment procedures were good and protected residents from possible abuse. All five comment cards returned from relatives said there were sufficient numbers of staff on duty. There were sufficient numbers of well trained to staff to meet the care needs of residents. The décor and furnishings at the home provided a homely atmosphere. Health and safety policies, procedures and equipment maintenance protected residents and staff from possible harm. 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. Abbeycroft Care and Nursing Home DS0000056843.V289613.R01.S.doc Version 5.1 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 Abbeycroft Care and Nursing Home DS0000056843.V289613.R01.S.doc Version 5.1 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): OP2 and OP3 The quality outcome for this standard group was good. This judgement has been made using available evidence including a visit to this service. Residents were assessed prior to their admission to the home to ensure they were suitably placed. Each resident had a copy of the terms and conditions for living at the home to ensure they were aware of their rights. EVIDENCE: Three residents case tracked had assessment documentation contained within the plans of care. The assessment documentation had been completed by a member of staff and a plan of care developed from the assessment. Further information was available from social services. The assessment of residents gave staff the knowledge to develop a plan of care and meet the needs of each individual. There was a contract for each resident. The document had been signed by a resident or a family member. Of 3 comment cards returned to the Commission for Social Care Inspection (CSCI) 2 residents had received a contract 1 resident did not know. The resident who was unsure commented, “I came here eight years ago because I could not return home. I can’t remember if I Abbeycroft Care and Nursing Home DS0000056843.V289613.R01.S.doc Version 5.1 Page 9 received a contract or not”. The contract document explained to residents the terms and conditions for living at the home. Abbeycroft Care and Nursing Home DS0000056843.V289613.R01.S.doc Version 5.1 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): OP7, OP8, OP9 and OP10 The quality outcome for this standard group was good. This judgement has been made using available evidence including a visit to this service. Plans of care contained good information for staff to deliver care to residents. Residents had access to specialists to meet their health care needs. Administration of medication was satisfactory. Residents were treated with respect and dignity to ensure they were comfortable with the personal care they received. EVIDENCE: Three residents were case tracked during the inspection. One resident was able to discuss care. Two staff members accurately described the care given to the resident’s case tracked. The plans of care, testimony of the staff member and resident accurately matched. One visitor present during the inspection said, “I am very happy with the way she is looked after here. I am always informed about her care and sometimes tell them what is going on”. Another visitor said, “They care for her 100 ”. Residents case tracked said, “I have been in here five years and Im all right. They treat me well. I don’t want to bother with my care as long as they give it to me and “The care here is excellent. I know whats happening to me. Due to my condition I cannot get out of bed very often but they help me when I do. The senior nurse is also excellent and goes out of her way to provide good care”. 3 comment cards returned to the CSCI said residents always (2) or usually (1) received the care and support Abbeycroft Care and Nursing Home DS0000056843.V289613.R01.S.doc Version 5.1 Page 11 they needed. Plans of care demonstrated resident or family involvement and had been reviewed on a regular basis. Plans of care contained sufficient information for staff to care for each resident. Plans of care examined during case tracking showed residents attended health care specialists. Specialists included Doctors, District Nurses, the Tissue Viability Nurse, Opticians and Chiropodists. One resident case tracked said, “I see the chiropodist regularly and the optician although he is hopeless but that’s not the homes fault”. Plans of care contained nutritional and pressure area assessments. One plan contained fluid balance charts, which had not been fully completed. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Plans contained a falls risk assessment. Of 3 comment cards returned to the CSCI all 3 residents thought they received the medical support they needed. Resident’s health care needs were met by attending health care specialists. There were policies and procedures for staff to follow for the administration of medication. There was a controlled drug cupboard and register. Drugs were securely stored. The medication administration chart was examined and contained no errors. There was a policy for the disposal of medication, recently updated to take account of a change in legislation. Records were maintained of medication entering and leaving the home. There was a British National Formulary and a copy of the Royal Pharmaceutical Societies guidelines. The deputy manager said, “I can contact the pharmacist and get the advice I need”. One resident case tracked said, “The deputy manager is very particular that pills arrive on time”. The good administration of medication protected residents from possible harm. Staff were observed to treat residents with privacy and dignity when delivering personal care. One resident case tracked and one visitor confirmed they were treated with privacy and dignity. Abbeycroft Care and Nursing Home DS0000056843.V289613.R01.S.doc Version 5.1 Page 12 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): OP12, OP13, OP14 and OP15 The quality outcome for this standard group was good. This judgement has been made using available evidence including a visit to this service. Leisure activities were provided to help residents live a fulfilling life. Visiting was open and unrestrictive to encourage families to enter the home. Residents were able to exercise choice and retained some independent living. Residents received an appealing and nutritious diet. EVIDENCE: One resident case tracked said, “I like listening to the talking books. I am nursed mostly in bed. I also like to watch television and listen to music. Staff visit me often and one lovely girl regularly comes in my room to talk for five minutes. She also writes letters for me”. A staff member said, “We try to get residents to join in and help those who can’t do it. We play card bingo, music and movement or just have sherry or other drinks and chocolates. We took three residents to the shop last week and two residents also went for a walk around the reservoir. There is an Italian evening next week”. One of the directors said, “The cook is laying on an Italian evening and it being well supported by residents and family members”. One resident said he was “very happy at the home but would like to go on more trips out”. 3 comment cards returned to the CSCI said activities were always available (1) or usually (2) available. Residents were observed watching television, playing games, Abbeycroft Care and Nursing Home DS0000056843.V289613.R01.S.doc Version 5.1 Page 13 reading and talking to each other. The range of activities was suitable for the resident group accommodated at the home. Visiting at the home was encouraged to help residents meet regularly with their families. One staff member said, “residents get up and go to bed when they like. If they don’t want to get up we will go back later. Some residents go to their rooms after tea. Some like to go to bed. Most residents go to bed between 7pm and 10pm. If they want to go to their rooms its their choice”. Another staff member said, “If residents want to go to bed they can do. Some are up late – it’s their choice. Nobody gets up before 7am”. One resident case tracked said, “I chose what I want to do. There is a choice of meals or what I want to do”. Staff members described residents being able to “choose their own clothes”, “getting up and going to bed when they liked” and “nobody is force fed, we try to encourage residents who do not wish to eat”. Residents were offered choice to help them retain some independence. One resident said, “on two days of the week there is no alternative and if I don’t like the menu I have sandwiches. One of the directors said, “We have a employed a new cook and there will be choice on the days the full time cook is off duty”. One resident case tracked said, “We have a new cook who is very innovative. The vegetables are sometimes overcooked but all in all the food is very good”. A meal was taken by the inspector and found it to be hot, nutritious and tasteful. Residents were observed to be fed in a discreet and individual manner prior to the mealtime. Tables were set with condiments and serviettes. Residents who were likely to spill food had their clothes protected by napkins. 3 comment cards returned to the CSCI said food was always good (1), usually good (1) or sometimes good (1). The cook carried out necessary environmental health checks and retained records. Food was generally to resident’s tastes. Abbeycroft Care and Nursing Home DS0000056843.V289613.R01.S.doc Version 5.1 Page 14 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): OP16 and OP18 The quality outcome for this standard group was good. This judgement has been made using available evidence including a visit to this service. Residents were aware of their right to complain and confidant to approach management with any concerns. Residents were protected from possible abuse. EVIDENCE: No complaints had been made to the home or CSCI since the last inspection. There was a complaints procedure with appropriate timescales. The complaints procedure highlighted the address of the Commission. Of 3 comment cards returned to the CSCI all three residents knew whom they would complain to and all 3 knew how to complain. All five comment cards returned to the CSCI from family members said they knew how to complain. Two had reason to complain in the past. One resident case tracked had, “No complaints”. Residents were able to voice their complaints and concerns. The home had a copy of the ‘No Secrets’ document. The home had policies and procedures for the protection of vulnerable adults. One member of staff said, “I am aware of the whistle blowing policy and would be prepared to use it if I saw anything wrong”. Another member of staff said, “I would tell the manager or directors if I witnessed any abusive incidents”. One resident case tracked said, “I have never seen or heard anything untoward”. One visitor said, “I have never heard staff talking to residents in a poor way. I see a lot from this room”. Residents were protected from possible abuse. Abbeycroft Care and Nursing Home DS0000056843.V289613.R01.S.doc Version 5.1 Page 15 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): OP19 – OP26 The quality outcome for this standard group was good. This judgement has been made using available evidence including a visit to this service. The environment met residents needs. Infection control policies and procedures protected the health and safety of residents and staff. EVIDENCE: A plan of routine maintenance had been developed. The plan highlighted areas of the environment that needed attention and the maintenance man followed the plan to upgrade the building.. A tour of the building was conducted. All the communal areas and a sample of the bedrooms were inspected. Bedrooms had been personalised to resident’s tastes. One resident case tracked said, “look around – its nice isnt it. Those are all pictures of family members”. All areas observed were well decorated, clean and free from offensive odours. One resident case tracked said, “the home is kept very clean, it never smells”. Of 3 comment cards returned to the CSCI all 3 said the home was kept clean. Toilets were near to communal and private space. Baths were suitable for disabled residents. Each room was lockable and had a lockable facility within the room. Windows had suitable restrictors to help protect the health and Abbeycroft Care and Nursing Home DS0000056843.V289613.R01.S.doc Version 5.1 Page 16 safety of residents. Hot water outlets were tested and did not pose a threat of scalding to residents. The environment was suitable to meet the needs of residents. There were policies and procedures for the control of infection. The laundry was sited away from food preparation areas and contained suitable equipment to clean clothes and bed linen. The walls and floors of the laundry were clean. Hand washing facilities were available where clinical waste was produced. One resident case tracked said, “the laundry is very satisfactory. I get through so many sheets but they just whip them away”. There were systems in place to protect residents from contracting Legionella. Infection control procedures protected residents and staff from possible harm. Abbeycroft Care and Nursing Home DS0000056843.V289613.R01.S.doc Version 5.1 Page 17 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): OP27, OP28, OP29 and OP30 The quality outcome for this standard group was good. This judgement has been made using available evidence including a visit to this service. Resident’s needs were met by the numbers and skill mix of a well-trained staff group. The recruitment procedures were not good and did not fully safeguard residents. EVIDENCE: All 5 comment cards returned to the CSCI from families said there were sufficient numbers of staff on duty. All 3 comment cards returned from residents said staff were available when they needed them. The off duty roster demonstrated there were sufficient numbers of staff on duty including trained nurses. One of the directors said, “there is one nurse on duty between 8am and 8pm supported by another nurse on duty between 8am and 4pm. There are 6 care staff between 8am and 12 midday, 5 care staff between midday and 5pm and 4 carers between 5pm until 10pm. Nights are covered by 1 trained nurse and 2 care staff. In addition there is a cook and kitchen assistant covering the main mealtimes and a kitchen assistant in the evening. There are 2 cleaners and a member of staff who works in the laundry. A maintenance man works between our two homes”. A training matrix to highlight staff training needs was not available on the day of the inspection. One of the directors of the home said, “there are 70 of staff who hold NVQ qualifications and we are hoping to start more staff on a NVQ course soon”. Staff spoken to during the inspection said, “I have taken Moving and handling training, fire awareness training, health and safety training, first aid training, tissue viability and wound care training and infection control training. I am waiting to start an NVQ course. I have recently had my appraisal and we discussed training needs” and “I finished my TOPPS induction, been trained in moving and Abbeycroft Care and Nursing Home DS0000056843.V289613.R01.S.doc Version 5.1 Page 18 handling and fire safety. I want to complete my NVQ soon. One of the directors said, “the registered manager who left in April had qualifications to be able to train staff in moving and handling and therefore most staff had received training”. The home employed sufficient numbers of suitably qualified staff to meet the needs of residents. Two staff files examined during the inspection contained evidence recruitment had been thorough. Files contained two references, a Criminal Records Bureau check, records of induction training, certification of courses undertaken and a protected record of NVQ qualification. Records of appraisal and supervision were also contained within the files. Recruitment procedures protected residents from possible abuse. Abbeycroft Care and Nursing Home DS0000056843.V289613.R01.S.doc Version 5.1 Page 19 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): OP31, OP33, OP35 and OP38 The quality outcome for this standard group was adequate. This judgement has been made using available evidence including a visit to this service. This judgement has been made using available evidence including a visit to this service. Quality assurance systems had been developed but needed some more work to fully meet the required standard. Resident’s financial interests were safeguarded. The health, safety and welfare of residents and staff was promoted and protected. EVIDENCE: One of the directors said, “We have tried to find a manager by advertising in the local press. The response we have had so far is from managers who were not qualified nurses. We intend to advertise nationally to fill the post. We have a qualified nurse as deputy manager and all three of us are taking the Registered Managers Award. We hope to have a manager in post as soon as possible”. The home must have a suitably qualified and competent manager registered with the CSCI. Abbeycroft Care and Nursing Home DS0000056843.V289613.R01.S.doc Version 5.1 Page 20 Quality assurance systems had not been developed since the last inspection. Resident’s had completed a questionnaire some time ago. The director involved in the inspection said, “We hold recorded meetings with residents and staff. Some of the documents for quality assurance are being held at our other home”. Quality assurance systems must be developed to take account the views of residents, family members, friends and significant others who visit the home such as District Nurses, Chiropodists or the hairdresser. The director said, “We control the finances of three clients and retain pocket money for several others. Two members of staff must sign the form when any money is given to residents”. The system was computerised. Money was held in an account with each resident’s monies recorded separately. The directors of the home audited the accounts. Residents were protected from possible financial abuse. Gas and electrical appliances and installations had been maintained. There was a health and safety policy and procedures. A health and safety poster was observed in the building. The registered manager had a copy of the legislation as detailed within the standard. Staff had been trained in health and safety issues such as first aid, health and safety, infection control, food hygiene and moving and handling. The health and safety systems helped protect the health and welfare of residents and staff. Abbeycroft Care and Nursing Home DS0000056843.V289613.R01.S.doc Version 5.1 Page 21 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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 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 2 X 2 X 3 X X 3 Abbeycroft Care and Nursing Home DS0000056843.V289613.R01.S.doc Version 5.1 Page 22 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 1 OP7 17(3)(a) The registered person must 31/07/06 ensure that records are accurately maintained for any resident who requires their dietary and fluid intake monitoring 2 OP31 8(1)(a)(b) The responsible individual must 30/08/06 employ a suitably qualified and experienced person to manage the home 3 OP33 24 The registered person must 31/07/06 ensure quality assurance meet current guidelines. 4 OP33 17 The registered person must 30/06/06 ensure all records required by the Commission for Social Care Inspection are retained at the home. 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 Good Practice Recommendations Standard 1 OP30 The registered person should ensure a training matrix is developed to highlight the training needs of staff and be available for inspection. Abbeycroft Care and Nursing Home DS0000056843.V289613.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB 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 Abbeycroft Care and Nursing Home DS0000056843.V289613.R01.S.doc Version 5.1 Page 24 - 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!