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Inspection on 25/07/05 for Abbeycroft Residential Care Home

Also see our care home review for Abbeycroft Residential Care Home for more information

This inspection was carried out on 25th July 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 home provides a homely and welcoming environment that enables service users to access all areas of the home and garden. Service users spoken to advised the inspector that the homes staff provide an excellent service and comments received included "staff are very nice" and " the food is really good here". The inspector witnessed staff interactions with service users and noted the obvious good relationships that were in place. Service user activities and leisure time provided by the home were found to be very good. Service users are able to participate in the home and the home facilitates and is always looking at ways in which service users can be more involved. The home provides adequate staffing levels to ensure service users wishing to participate in local facilities are supported when necessary. Some service users go out alone and this is supported by suitable documentation. Most of the staff working at the home are trained to NVQ 2 level and staff spoken to displayed a commitment to providing a high standard of care and support to the service users living at the home. All staff displayed an understanding of service user needs. The home is committed to ensuring its staff team are trained and the home offers and supports staff in their training aspirations.

What has improved since the last inspection?

Staff and service users commented on how the home is nicer to live in since the new manager has been in position. The home has acted upon all of the legal requirements brought to their attention at the last inspection, however, some areas are still required to be further developed and completed. The home has started to implement a programme of decoration and empty rooms have been decorated prior to new service users moving in.

What the care home could do better:

Whilst the home has started to repair and replace damaged items there remains some outstanding items. The home is required to implement a programme of maintenance and replacement of equipment. Whilst the inspector did not audit the homes quality monitoring systems, and the home does undertake service user meetings, the home has not started the process of consultation with service users and other stakeholders of the business. This will be audited at the next inspection. The home had completed care plans for service users, however, some areas of concern had not been documented and furthermore no risk assessments for service users had been completed. The home had not fitted window restrictors to all rooms on the first floor to prevent service users falling from a height. A requirement has been made. The home needs to ensure all rooms are kept clean.One service user had been admitted without a suitable assessment being carried out by the home. This therefore meant that the home was unsure if the service users needs could be met. The home is required to implement a suitable assessment and admission practices for future service users moving into the home.

CARE HOMES FOR OLDER PEOPLE Abbeycroft Residential Care Home 147 Swift Road Woolston Southampton SO19 9ES Lead Inspector Lorraine Parton Unannounced 25 July 2005 11:00 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Abbeycroft Residential Care Home 20051017 H55-H03 S41730 abbeycroft V224280 250705.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Abbeycroft Residential Care Home Address 147 Swift Road, Woolston, Southampton, Hampshire, SO19 9ES Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 023 8042 0820 023 8057 94444 Abbeycroft Care Limited Mrs Paula Blake Care Home 20 Category(ies) of Dementia - over 65 years of age (20), Old age, registration, with number not falling within any other category (20) of places Abbeycroft Residential Care Home 20051017 H55-H03 S41730 abbeycroft V224280 250705.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 2/11/04 Brief Description of the Service: Abbeycroft is a care home that is registered for 20 service users within the category of older persons and varying levels of dementia. The home is situated in Woolston a quiet area of Southampton. The home offers accommodation with eighteen single and one double bedroom. On the ground floor of the home there is a lounge, dining room, kitchen and several bathroom and toilets. On the first floor is a range of service user bedrooms and facilities for bathing and personal needs. The front of the property is accessed via a small drive which provides parking facilities for staff and visitors to the home. The home is surrounded by a nicely maintained garden that facilitates access for service users wishing to use this area. The home is situated close to local facilities and a short journey away from the city of Southampton. Abbeycroft Residential Care Home 20051017 H55-H03 S41730 abbeycroft V224280 250705.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place in the presence of the new registered manager Paula Blake and lasted for 5.5 hours. The previous registered manager who was also one of the providers had resigned these positions since the last inspection. The home is owned by Abbeycroft Care Limited. This was Mrs Blake first inspection since registration and she was found to be professional and displayed her awareness of the service users needs and the service being provided. A walk around the home was carried out and some areas within the home were inspected. The inspector spoke to many of the service users living at the home and received positive comments about the care they received. The inspector also had the opportunity to speak to two visitors and one visiting professional who were positive about the service/care the home provides. The inspector audited some of the homes documentation that relates to the provision of care. The inspector received ten comment cards from service users and visitors to the home. Comments received in them were found to be positive about the services they or their relatives received. Service users confirmed that they were happy living at the home. Two comment cards received indicated that service users are not aware of whom to raise concerns with. This has been included in the main part of this report. The registered manager in preparation for the inspection had completed the providers self audit which greatly assisted the inspector in carrying out the inspection process. The self-audit demonstrated that the service have an open, honest and transparent approach to the service they provide. What the service does well: The home provides a homely and welcoming environment that enables service users to access all areas of the home and garden. Service users spoken to advised the inspector that the homes staff provide an excellent service and comments received included “staff are very nice” and “ the food is really good here”. The inspector witnessed staff interactions with service users and noted the obvious good relationships that were in place. Service user activities and leisure time provided by the home were found to be very good. Service users are able to participate in the home and the home Abbeycroft Residential Care Home 20051017 H55-H03 S41730 abbeycroft V224280 250705.doc Version 1.40 Page 6 facilitates and is always looking at ways in which service users can be more involved. The home provides adequate staffing levels to ensure service users wishing to participate in local facilities are supported when necessary. Some service users go out alone and this is supported by suitable documentation. Most of the staff working at the home are trained to NVQ 2 level and staff spoken to displayed a commitment to providing a high standard of care and support to the service users living at the home. All staff displayed an understanding of service user needs. The home is committed to ensuring its staff team are trained and the home offers and supports staff in their training aspirations. What has improved since the last inspection? What they could do better: Whilst the home has started to repair and replace damaged items there remains some outstanding items. The home is required to implement a programme of maintenance and replacement of equipment. Whilst the inspector did not audit the homes quality monitoring systems, and the home does undertake service user meetings, the home has not started the process of consultation with service users and other stakeholders of the business. This will be audited at the next inspection. The home had completed care plans for service users, however, some areas of concern had not been documented and furthermore no risk assessments for service users had been completed. The home had not fitted window restrictors to all rooms on the first floor to prevent service users falling from a height. A requirement has been made. The home needs to ensure all rooms are kept clean. Abbeycroft Residential Care Home 20051017 H55-H03 S41730 abbeycroft V224280 250705.doc Version 1.40 Page 7 One service user had been admitted without a suitable assessment being carried out by the home. This therefore meant that the home was unsure if the service users needs could be met. The home is required to implement a suitable assessment and admission practices for future service users moving into the home. 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 Residential Care Home 20051017 H55-H03 S41730 abbeycroft V224280 250705.doc Version 1.40 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Abbeycroft Residential Care Home 20051017 H55-H03 S41730 abbeycroft V224280 250705.doc Version 1.40 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2, 3, 5 All service users have a contract of tenancy that includes terms and conditions. The home usually undertakes effective assessments that ensure identified needs are able to be met by the service. Service users are afforded the opportunity to visit the home before moving in. EVIDENCE: Five service user files were audited by the inspector and were found to include signed copies of their contract of tenancy. Contracts were found to contain all relevant information. Service users spoken to advised the inspector that they were aware of their contracts and one service user stated their family had dealt with all the formalities for them. Four files contained adequate assessments undertaken by the home. One service user had been admitted without an assessment being carried out by the home. This admission had occurred between the employment of managers. The home is reminded that the registered manager must be responsible for the admission of new service users. A requirement is made for the assessment of service users to be undertaken prior to agreeing admission. Abbeycroft Residential Care Home 20051017 H55-H03 S41730 abbeycroft V224280 250705.doc Version 1.40 Page 10 The inspector had the opportunity to speak to two new service users who confirmed that they and/or their representatives visited the home prior to agreeing to move in. Service users confirmed they had been given information in the form of the service user guide before moving in. The home does not offer intermediate care facilities. Abbeycroft Residential Care Home 20051017 H55-H03 S41730 abbeycroft V224280 250705.doc Version 1.40 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 10, 11 All service users have a care plan. Some care plans are in need of development to include specific issues and identified needs. All service users health care needs have been assessed and where necessary they have access to relevant health care professionals. Service users confirmed that the homes staff, treat them with dignity and that their privacy is respected at all times, although staff do not knock on service users doors before entering. Service users wishes are documented in the event of death. The home has policies and procedures in place to ensure service users are supported in the home whilst ever their needs can be met. EVIDENCE: The inspector audited five service user plans, which were found to contain relevant care planning information, health care professional involvement where necessary and records of reviews. The wishes of service users in the event of death and illness are clearly recorded in the service user plans. Care plans seen were basic and risk assessments had not been completed for any service users. One new service users file displayed that an assessment of needs had Abbeycroft Residential Care Home 20051017 H55-H03 S41730 abbeycroft V224280 250705.doc Version 1.40 Page 12 not been undertaken. Service user files where relevant did not include a moving and handling assessment, risk assessments for those service users who wander and for those service users who are at risk of falling. This was discussed with the home and it was agreed that all care plans would be reviewed and amended in accordance with service user needs. The home is required to undertake risk assessments and incorporate these into service user plans. All service users are afforded access to relevant health care professionals and service users are registered with a general practitioner of their choice. The inspector had the opportunity to speak to a visiting health care professional who advised the inspector that the home provides a good level of care and support to service users who require assistance. Service users spoken to confirmed that the homes staff, respect their views and the need for their privacy and dignity to be up held. One service user advised the inspector that staff do not knock on his room door and that staff enter and do what they want without discussing this with him. Whilst talking to the service user in his room, a member of staff just walked in and the inspector witnessed this was the case. On speaking to other service users this was not evidenced further and service users stated that they “always knock on my door before coming in my room”. During the discussions with staff and the homes manager this was discussed and it was agreed that this would be addressed during the next staff meeting. Staff were seen by the inspector to be interacting with service users in an equal and respectful manner. Service users confirmed that they receive personal care in private and are able to receive treatments and consultations in their bedrooms in private. Abbeycroft Residential Care Home 20051017 H55-H03 S41730 abbeycroft V224280 250705.doc Version 1.40 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14, 15 Service users are supported in their chosen lifestyles and encouraged to make choices about their lives. Service users are supported in whom they choose to have contact with. All service users are supported if necessary with access to the community. Service users confirmed that the home provides excellent food of their choice. EVIDENCE: All service users choices in lifestyles and preferences in activities are documented in service user plans. Service users spoken to advised the inspector that the home provides activities and facilities that meet their personal wishes. Service users confirmed that the homes staff ask them what they want and do their best to provide or support community access if needed. One service user has maintained their place at a day centre one day per week and access is supported by the homes staff if necessary. Abbeycroft Residential Care Home 20051017 H55-H03 S41730 abbeycroft V224280 250705.doc Version 1.40 Page 14 Some service users go out alone and access local facilities of their choice. This includes shopping. Service users, who are unable to go out alone are supported by the staff. Service users confirmed, that the homes staff, take them out occasionally and that they enjoy this facility. The home offers a range of in house activities and this includes games, musical sessions, bingo and singalongs. The home has a activities person who provides a range of activities including games and reminiscence groups. Service users who wish to participate in the home are able to do so, service users were seen to be participating in the home during the inspection, which included laying tables and tidying up. Service users spoken to confirmed that the home supports their choices in involvement in the home. Service users who wish have personalised their rooms and some rooms contain service users own furniture and belongings. Service users confirm that they have access to television and music in their rooms if they wish. The home has a visiting policy, which affords and encourages visitors at any reasonable time. Service users confirmed that they are able to see visitors in private in their own rooms and elsewhere in the home if not in use by other service users. A visitor to the home confirmed that they were able to visit when they wished and that the homes staff always made them feel welcome. Service users spoken to stated that the home provides good food and offers a choice of menu. Menus display a well balanced and nutritious variation, which, the staff stated are based on service users likes and dislikes. Individual choices and needs in food are catered for and this includes likes, dietary needs and special requests. The inspector was present for the lunch time meal and it was noted to be well presented and nutritious. Meal times were noted to be relaxed and service users who were being supported were not rushed and their dignity was maintained. One service user at the time of the inspection was experiencing difficulties with maintaining a balanced diet. The home had obtained advise from the GP, encouraging diet and a record of food eaten was being maintained. One carer at the time of the inspection was cooking the lunch and at times was being assisted by the other carers. Whilst in the kitchen this left the dining room unsupervised by the staff. This was discussed and the homes manager agreed to review how staff cover meal times. Abbeycroft Residential Care Home 20051017 H55-H03 S41730 abbeycroft V224280 250705.doc Version 1.40 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 17, 18 Service users are aware of how to make a complaint and to whom. Service users who wish to take part in the election process. The home has procedures and practices in place to protect where possible service users. EVIDENCE: The manager advised the inspector that all service users are given a copy of the homes complaints procedure on admission. A copy of the complaints procedure was on display on the notice board in the home. Service users confirmed that they were aware of the complaints procedure and that the homes staff had gone through it with them. Service users advised the inspector that they would speak to the homes manager or staff if they had any concerns and if unresolved would speak to their families or friends. The home has not received any complaints since August 2004. A record of a complaint would be maintained if necessary. A complaint received by the Commission for Social Care Inspection was discussed in the inspection and was dealt with separate to this report. During the inspection one service users raised concerns about staff not knocking on their doors before entering and noisy staff during the night. These were discussed with the homes manager who agreed to raise these issues with staff and take appropriate action. Abbeycroft Residential Care Home 20051017 H55-H03 S41730 abbeycroft V224280 250705.doc Version 1.40 Page 16 The registered manager advised the inspector that all service users are registered to vote and that two service users take part in the election process. The home has a copy of Hampshires Adult Protection procedure and a whistle blowing policy. The home has not got a copy of the reviewed policy issued in 2004, the home has agreed to obtain a copy of the up to date procedure from Social Services. On speaking to staff they displayed their awareness of what constitutes abuse and the appropriate action to take if necessary. All staff have received training in adult protection issues through the NVQ 2 course. Abbeycroft Residential Care Home 20051017 H55-H03 S41730 abbeycroft V224280 250705.doc Version 1.40 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 standard(s) 19, 20, 23, 24, 25, 26 Risk assessments have been undertaken but need updating and some areas of risk are not controlled, posing a risk to service users. Some areas of the home were in need of repair and cleaning. The home provides a homely environment for service users. Service users who wish have personalised their bedrooms with their own belongings. EVIDENCE: The inspector undertook a walk around the home and identified two bedrooms and the shower room needed cleaning, one commode that had not been emptied, damaged flooring around a sink and some rooms including bedrooms that needed decorating. The dining room carpet is damaged and posing a tripping accident to service users who have poor mobility. The home is required to ensure that a cleaning and maintenance schedule is implemented. Abbeycroft Residential Care Home 20051017 H55-H03 S41730 abbeycroft V224280 250705.doc Version 1.40 Page 18 Furthermore, the home has not updated the risk assessments, and implemented controls for identifiable risks. This included for example moving and handling, legionella, and use of the kitchen. Some first floor rooms have not been fitted with window restrictors to prevent service users falling from a height. The home is required to undertake risk assessments and fit window restrictors to first floor windows. Mainly the home was found to be homely, clean and suitable for service users. All areas of the home are accessible to service users and the rear garden was found to be well maintained. At the time of the inspection service users were seen to be moving around the home and several service users were in the garden as they chose. All rooms seen were found to include service users own possessions and some rooms contained service users own furniture. The inspector noted that these rooms were homely and service users own choice. Abbeycroft Residential Care Home 20051017 H55-H03 S41730 abbeycroft V224280 250705.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29, 30 The home had adequate staff on duty, who were found to be well trained and competent to do their jobs. Service users are safe. The home has implemented suitable recruitment procedures. EVIDENCE: Three staff and the homes manager were on duty at the time of the inspection. Staff confirmed that the home is covered by four staff in the morning and three staff in the afternoon. The inspector had access to the homes rota, which also confirmed the above. Eight of the thirteen carers employed in the home have completed the NVQ level 2 training and two carers are completing NVQ 3 at present. Staff advised the inspector that they have also completed additional training in moving and handling, medication, infection control, basic food hygiene, COSHH and fire. Two staff have completed a course in adult protection and the home is planning courses in the future for adult protection, food hygiene, dementia and pressure care for staff that have not completed these courses. Service users confirmed that they felt safe in the home and that the homes staff are always supportive and professional in their approach. The home has policies and procedures in place to protect vulnerable adults and some staff Abbeycroft Residential Care Home 20051017 H55-H03 S41730 abbeycroft V224280 250705.doc Version 1.40 Page 20 have received training in this area. On speaking and questioning staff they displayed their awareness and understanding of the homes policies on reporting any issues that may be abuse and how to maintain privacy and the dignity of the service users living at the home. Staff displayed an excellent awareness of service user needs and advised the inspector of the promotion of individual needs and how these are met. Two staff files were audited by the inspector and found to contain all the relevant information. This included two references, CRB and POVA checks, application form and records of interviews. Staff files contained information regarding training courses and a record of regular supervisions undertaken by the homes manager. Abbeycroft Residential Care Home 20051017 H55-H03 S41730 abbeycroft V224280 250705.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) none EVIDENCE: The inspector did not audit the management of the home due to the manager being new. Staff advised the inspector that the manager was approachable and that in their opinions the standards within the home have improved. Staff stated that the manager operates an open door policy and is holding regular meetings to ensure that service users needs are being met. The registered manager has worked in the home for many years and has completed the NVQ 4 in care and has completed the registered managers award, which displays her commitment to the home. These standards will be fully assessed at the next inspection. Abbeycroft Residential Care Home 20051017 H55-H03 S41730 abbeycroft V224280 250705.doc Version 1.40 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 2 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 2 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 3 x x 3 3 2 2 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 Standard No 16 17 18 Score 3 3 3 x x x x x x x x Abbeycroft Residential Care Home 20051017 H55-H03 S41730 abbeycroft V224280 250705.doc Version 1.40 Page 23 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard 3 7 Regulation 14(1) 15(2) Requirement Implement a suitable assessment of prospective service users Further develop service user plans to include specific information and incorporate risk assessments in to service user plans. Undertake further risk assessments for the home. Implement a suitable cleaning schedule Repair or replace the remaining damaged carpets. Implement a programme of repairs for outstanding maintanance items. Fit window restrictors to first floor rooms that do not have them fitted. Fit window restrictors to first floor rooms that do not have them fitted. Timescale for action 30/11/05 30/11/05 3. 4. 5. 38 26 22 13(4) 16(2)(k) 23(2) 30/11/05 30/11/05 30/11/05 6. 7. 38 19 13(4) 13(4) 30/11/05 30/11/05 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 20051017 H55-H03 S41730 abbeycroft V224280 250705.doc Version 1.40 Page 24 Abbeycroft Residential Care Home Standard 1. Abbeycroft Residential Care Home 20051017 H55-H03 S41730 abbeycroft V224280 250705.doc Version 1.40 Page 25 Commission for Social Care Inspection 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 Abbeycroft Residential Care Home 20051017 H55-H03 S41730 abbeycroft V224280 250705.doc Version 1.40 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!