Inspection on 12/08/05 for Abbeyfield Ilkley Society Limited

This inspection was carried out on 12th August 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.

Other inspections for this house

Abbeyfield Ilkley Society Limited 19/09/08

Abbeyfield Ilkley Society Limited 20/09/07

Abbeyfield Ilkley Society Limited 12/12/06

Abbeyfield Ilkley Society Limited 09/02/06

Abbeyfield Ilkley Society Limited 25/08/04

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

CARE HOMES FOR OLDER PEOPLE Abbeyfield Ilkley Society Ltd 12 Riddings Road Ilkley West Yorkshire LS29 9BF Lead Inspector Steve Marsh Unannounced 12th August 2005 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. Abbeyfield Ilkley Society Ltd J52 J03 S59448 Abbeyfield V194994 020805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Abbeyfield Ilkley Society Ltd Address 12 Riddings Road Ilkley LS29 9DF 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) 01943 886000 Abbeyfield Ilkley Society Ltd Ms Fiona Jayne Collins Care Home Only 15 Category(ies) of Old Age (15) Physical Disability (1) registration, with number of places Abbeyfield Ilkley Society Ltd J52 J03 S59448 Abbeyfield V194994 020805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 25/08/04 Brief Description of the Service: Abbeyfield Care Home was first registered in May 2004 and is located within the Abbeyfield complex which also provides a number of other facilities for the elderly including sheltered housing and a day centre. The home is registered to care for fifteen residents on both a long stay and respite care basis. The accommodation consists of spacious en-suite single bedrooms and well appointed communal lounge and dining room areas. In addition there is also a communal assisted bathroom and toilet facilities conveniently situated throughout the home. All the bedrooms and communal facilities are on one floor of the building (first floor) and there is a passenger lift available. The home is located in the Ilkley areas very close to the main shopping area and within easy walking distance of local churches, town centre amenities and local transport. Abbeyfield Ilkley Society Ltd J52 J03 S59448 Abbeyfield V194994 020805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first unannounced inspection for the year 2005/06, and was carried out by one Inspector over a period of about eight hours. The last inspection of this service was in August 2004 and the main purpose of this visit was to assess the homes progress in meeting the requirements and recommendations made at that time. The methodology used in this inspection included the examination of records, observation of work practices, discussions with residents, visitors and staff and a tour of the building. Comment cards were provided for the residents and/or their relatives to enable them to share their views of the service with the Commission; comments received in this way will be fed back to the registered manager of the home without revealing the identity of the respondent. This was the Inspectors first visit to Abbeyfield and therefore he would like to take the opportunity to thank the manager, members of the staff team, residents and visitors who participated in the inspection process. People living at the home prefer to be referred to as residents and not service users in inspection reports. Feedback was given to Mrs Fiona Collins (registered manager) at the end of the visit. Requirements and recommendations from this inspection are detailed at the end of the report. What the service does well: The home provides a pleasant, comfortable and safe environment for the residents and the staff team are approachable and appear to have a genuine understanding of their needs. The admission procedure for the home is thorough and the manager will not admit residents unless she feels that the staff team can provide the level of care/support they require. Residents are supported in making decision about their daily lives and are able to join in many of the activities taking place in other parts of the complex. Abbeyfield Ilkley Society Ltd J52 J03 S59448 Abbeyfield V194994 020805 Stage 4.doc Version 1.40 Page 6 The resident’s healthcare needs appear to be met and any problems are identified at an early stage and a referral made to the appropriate professional agency. There is a commitment to staff training, both to meet the needs of the residents and for personal development and staff appear to be aware of their roles and responsibilities. The home is well managed and the views and opinions of the residents are actively sought to ensure that they are receiving the standard/level of care and/or support they require. What has improved since the last inspection? What they could do better: The manager needs to ensure that two written references are obtained for new members of staff prior to them commencing employment, and that there is always a senior care assistant on night duty with the experience and skills to manage the home. In addition the manager must also ensure that the cleaning hours at the home are adequate and meet the needs of the residents and service. Members of the senior care staff need to be more vigilant when signing the medication administration record sheets and a stock control system is required for medication administered on a prn (as and when required) basis. Abbeyfield Ilkley Society Ltd J52 J03 S59448 Abbeyfield V194994 020805 Stage 4.doc Version 1.40 Page 7 Although the home presently make quality assurance questionnaires available to the residents, the system should be developed further to include their relatives and other professionals accessing the service i.e. general practitioners, district nurses etc. 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. Abbeyfield Ilkley Society Ltd J52 J03 S59448 Abbeyfield V194994 020805 Stage 4.doc Version 1.40 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Abbeyfield Ilkley Society Ltd J52 J03 S59448 Abbeyfield V194994 020805 Stage 4.doc Version 1.40 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4,5 Residents and/or their relatives are provided with sufficient information to enable them to make informed decisions about the home. The admission procedure is good and includes pre-admission assessment visits, introductory visits and trial periods if appropriate. EVIDENCE: The manager confirmed that there had been no changes to the homes statement of purpose or service user guide and both documents are available to both existing and prospective residents as required. Both documents have also been given to the talking newspaper and will be available on audiotape in the near future, which is good practice. At the present time the home has ten long-stay beds and five respite care beds and it is the manager’s intention to keep this balance, as it appears to work well for the service. Abbeyfield Ilkley Society Ltd J52 J03 S59448 Abbeyfield V194994 020805 Stage 4.doc Version 1.40 Page 10 The records examined provided evidence that pre-admission assessment visits are carried out to see prospective residents either in their own home or temporary place of residence, and the needs identified during this visit are reflected in their initial care plan. In addition to the pre-assessment visit all prospective residents and/or their relatives are invited to visit the home prior to admission to view the accommodation, meet the other residents and staff and stay for a meal if they wish to do so. Residents spoken to, confirmed that the staff had been very helpful when they had initially visited the home looking for a place, had shown them around, answered any questions and provided general information about the care/service provided. One resident staying at the home for a two-week period said the manager and staff team had been very kind and supportive, and the admission procedure had been much easier than she expected. Another resident confirmed that she had enjoyed her stay so much that she had booked a further period of respite care over the Christmas period. The manager confirmed that the maximum stay for a respite care resident is six weeks but the home is happy to admit residents for shorter periods of time including weekend stays etc. Long-stay residents are also able to move into the home for a trial period to enable them and/or their relatives make an informed decision about their future care. All residents are issued with a contract on admission to the home, which is signed by both them and the manager as required. Staff training continues to be actively encouraged at the home both to meet the needs of the residents and for personal development. Abbeyfield Ilkley Society Ltd J52 J03 S59448 Abbeyfield V194994 020805 Stage 4.doc Version 1.40 Page 11 Abbeyfield Ilkley Society Ltd J52 J03 S59448 Abbeyfield V194994 020805 Stage 4.doc Version 1.40 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10 Records and reports about the resident’s welfare show that their healthcare needs are met and any problems are identified at an early stage and the appropriate referral made. However, the manager needs to ensure that senior members of staff are more vigilant when administering medication to safeguard the residents. EVIDENCE: Care plans have been completed for all residents on both long-stay and respite care placements and there is sufficient evidence in the documentation to show that residents and/or their relatives are involved in the care planning process. Care plans are reviewed on a monthly basis for residents living at the home on a long-stay basis and weekly for residents on respite care placements. It was however noted that in some instances information was difficult to find within the present format and therefore the manager was reminded that the plan is a working document and should be more user friendly. Abbeyfield Ilkley Society Ltd J52 J03 S59448 Abbeyfield V194994 020805 Stage 4.doc Version 1.40 Page 13 In addition to care plans risk assessments have also been completed for individual residents where specific areas of concerns have been identified. All residents are registered with a general practitioner and have access to the full range of NHS services. Residents who do not live in the area but are admitted to the home for respite care are registered with a local medical practice on a temporary basis unless their general practitioner will travel to see them. The manager confirmed that since the home opened a good working relationship has been established with the district nursing service and other healthcare professionals, to ensure that the needs of the residents are fully met. Residents spoken to, said that prompt medical was always sought if they felt unwell, which they found very reassuring and that medical examination were always carried out in the privacy of their own rooms. Relatives also confirmed that they were kept informed of any changes in the resident’s general health and were given the opportunity to meet healthcare professionals involved in their care if they wished to do so. It was apparent through observation and discussion with the residents that the staff treat them with respect and have a genuine understanding of their needs. On reviewing the medication system in place four discrepancies were noted whereby staff had not signed or coded the medication administration record (MAR) sheet correctly. In addition a stock control system is required for medication prescribed for residents on prn (as and when required) basis. At present three residents keep and administer their own medication and there is a lockable facility in their room to enable it to be stored securely. The manager confirmed that the staff team continue to monitor the general health of residents taking long-term medication and the pharmacist and/or their general practitioner would be contacted if concerns were raised. Abbeyfield Ilkley Society Ltd J52 J03 S59448 Abbeyfield V194994 020805 Stage 4.doc Version 1.40 Page 14 Abbeyfield Ilkley Society Ltd J52 J03 S59448 Abbeyfield V194994 020805 Stage 4.doc Version 1.40 Page 15 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) 12,13,15 The home offers a range of social and leisure activities and residents are encouraged to make informed decisions about their lifestyle. Meals appear nourishing and take into account the likes and dislikes of the residents. EVIDENCE: The daily routines of the home appear flexible and are based around the needs of the residents. The manager confirmed that a member of the senior care staff team has been designated as the activities co-ordinator for the home, although other members of the staff also provide activities/outings for the residents. In addition residents staying at the home on a respite care basis are able to attend the day centre based in the complex provided that they usually attend the centre when living in the community. Residents living at the home on a long-stay basis do not have access to the day centre but can join in other actives organised within the Abbeyfield complex. Abbeyfield Ilkley Society Ltd J52 J03 S59448 Abbeyfield V194994 020805 Stage 4.doc Version 1.40 Page 16 A newsletter is published to keep residents informed of forthcoming events, birthdays etc. The manager confirmed that the home has strong links with the local community and the resident use the shops and other facilities in Ilkley and support community events. The manager also confirmed that religious leaders from all denominations visit the home on a regular basis and church services are held within the complex, which the residents can attend. In addition the home would also make arrangements for residents to attend church etc if they wished to do so. Residents spoken to appeared very happy with the level of activities organised for them, and liked the fact that they were able to decide whether or not they wanted to join in activities or plan their own daily routine. Relatives spoken to, confirmed that they were able to visit the residents at any time, were always made to feel welcome by members of staff and offered a meal or light refreshments. Relatives also confirmed that they were able to see residents in the privacy of their own room or one of the communal areas within the home or complex. The meals at the home where described by the residents as very good both in quality and presentation and they confirmed that in addition to the dining room they could also use the restaurant situated on the ground floor of the complex at lunchtime. Hot and cold drinks are freely available to the residents both day and night on request. Abbeyfield Ilkley Society Ltd J52 J03 S59448 Abbeyfield V194994 020805 Stage 4.doc Version 1.40 Page 17 Abbeyfield Ilkley Society Ltd J52 J03 S59448 Abbeyfield V194994 020805 Stage 4.doc Version 1.40 Page 18 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) 16,18 Robust complaint and adult protection policies and procedures ensure that the residents are listened to, and protected from any form of abuse. EVIDENCE: The home has a complaints procedure and residents and relatives spoken to on the day of the visit said that they were aware of the procedure and knew what to do if they were unhappy with the care/service provided. The manager confirmed that no complaints had been received since the last inspection visit. Policies and procedures are in place at the home in relation to adult protection and with the exception of one member of night staff all staff have received adult protection training provided by the Local Authority. Members of staff spoken to confirmed that they were aware of the homes policy on “whistle blowing” and their responsibility to safeguard the residents from all forms of abuse. The manager is also aware of the Protection Of Vulnerable Adults register and the implications this has had on the homes staff recruitment, selection and disciplinary procedures. Abbeyfield Ilkley Society Ltd J52 J03 S59448 Abbeyfield V194994 020805 Stage 4.doc Version 1.40 Page 19 A policy document is available in relation to handling the residents financial affairs, which does not allow members of staff to be involved in the making of, and/or benefiting from their wills. Abbeyfield Ilkley Society Ltd J52 J03 S59448 Abbeyfield V194994 020805 Stage 4.doc Version 1.40 Page 20 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) 19,20,21,22,23,24 The home provides a very pleasant, comfortable and safe environment for the residents and they are also able to use many of the other facilities within the Abbeyfield complex. EVIDENCE: The home was opened and first registered on the 7th May 2004 and is located within the Abbeyfield complex, which is an imposing building close to Ilkley Town centre offering a variety of services/accommodation to elderly people. The home provides well-planned spacious accommodation for fifteen residents in single en-suite bedrooms and as very pleasant communal lounge and dining room areas. All the bedrooms are furnished to a high standard and there was evidence of the resident’s personal belonging in most room, which made them individual and homely. Abbeyfield Ilkley Society Ltd J52 J03 S59448 Abbeyfield V194994 020805 Stage 4.doc Version 1.40 Page 21 In addition to the en-suite facilities available in every bedroom there are also communal toilet facilities conveniently situated throughout the home and two communal bathrooms. The manager would however like to change the use of one of the bathrooms, which is not used, to provide additional and much need storage space and it was agreed that the proposal be put in writing to the Commission for consideration. A discussion was also held with the manager regarding the need to fit grab rails in two toilets to assist the residents to use the facility independently. Residents and relatives spoken to confirmed that they were very happy with the standard of accommodation and found that the small group living arrangement worked very well and helped to create an homely atmosphere. A recent visit by the fire safety officer has however highlighted that some work is still required to maintain the present standard of fire protection at the home and the registered provider is presently addressing this matter. Abbeyfield Ilkley Society Ltd J52 J03 S59448 Abbeyfield V194994 020805 Stage 4.doc Version 1.40 Page 22 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 has now established a stable care staff team, which ensures that the residents receive continuity of care. The manager must however ensure that the recruitment process is thorough and that there is always a senior member of the care staff team on wakeful night duty to safeguard the residents. In addition the cleaning hours must be reviewed to ensure they are sufficient to meet the needs of the service. EVIDENCE: A rota for the week of inspection was taken which showed that sufficient numbers of care staff are employed on day and night duty to meet the needs of the residents. The manager confirmed that at the present time the home only has one vacancy for a member of night staff, and a date had been arranged to interview prospective candidates for the post. The manager confirmed that the home continues to occasionally employed agency staff, however the permanent staff team is now becoming well established and the use of agency staff is minimal. A discussion was held with the manager regarding the night staffing arrangements at the home and the need to ensure that one of the two Abbeyfield Ilkley Society Ltd J52 J03 S59448 Abbeyfield V194994 020805 Stage 4.doc Version 1.40 Page 23 members of staff on wakeful night duty is a senior care assistant, designated to take charge of the shift. All members of care staff providing personal care are over eighteen years of age and all senior members of staff are over twenty-one years of age in line with the National Minimum Standards. The manager confirmed that the homes recruitment and selection procedures for new employees is thorough and includes the taking up of two written references and a Criminal Record Bureau (CRB) check. On reviewing two staff files it was however noted that for one new employee only one written reference hade been received prior to her commencing employment and therefore this matter must be addressed. All new members of staff receive induction and foundation training, following which there is an expectation that they will study for a National Vocational Qualification (NVQ) at level two or above depending on the post they hold. Additional training both to meet the needs of the residents and for personal development is also encouraged and the staff training records gave clear evidence of the homes commitment to training. Members of the care staff spoken to confirmed that the home provided very good training opportunities and that the manager always supported them when applying for training courses. Abbeyfield does not employ its own cleaning staff but employs contract cleaners to ensure that the home is kept clean and free from offensive odours. The manager confirmed that three cleaners are allocated forty-five minutes each morning to clean the home, however it was evident on the day of the visit and they were rushing to complete the task in the allocated time. The manager must therefore review the cleaning staff hours to ensure that they are adequate and meet the needs of the service . Abbeyfield Ilkley Society Ltd J52 J03 S59448 Abbeyfield V194994 020805 Stage 4.doc Version 1.40 Page 24 Abbeyfield Ilkley Society Ltd J52 J03 S59448 Abbeyfield V194994 020805 Stage 4.doc Version 1.40 Page 25 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) 31,32,33,35,36,38 The home is well run and the manager provides good leadership to the staff team and ensures that the resident’s rights are protected and their needs are met in line with their care plan. Policies and procedures are in place to ensure the health and safety of the residents, visitors and members of the staff team. EVIDENCE: Mrs Fiona Collins was registered by the Commission has the manager of the home in June 2005 and she is presently studying for the Registered Managers Award. Abbeyfield Ilkley Society Ltd J52 J03 S59448 Abbeyfield V194994 020805 Stage 4.doc Version 1.40 Page 26 Mrs Collins appears to communicate a clear sense of direction and leadership to the staff team, and members of staff confirmed that she has an open and approachable management style. The staff also said that they enjoyed working at the home and felt well supported in their work by the manager and senior staff team. The manager ensures clear channels of communication with the staff by holding regular staff meetings and formal one to one supervision with individual members of staff take place at least every two months in line with the National Minimum Standards. In addition the manager works within the home on a daily basis and is therefore on hand to deal with any quires/concerns raised either by the staff or residents. Residents meeting have also recently started at the home and the results of a recent resident’s satisfaction questionnaire were made available to the Inspector on the day of the visit. The manager was however reminded that the quality assurance surveys should not only involve the residents but also their relatives and other professional who access the service i.e. general practitioners etc. As recommended in the last inspection report the home will now hold money in safekeeping for residents and transaction sheets are available showing income, expenditure and a balance. Policies and procedures are in place to ensure the health and safety of the residents, visitors and staff and they are reviewed on a regular basis to ensure they comply with present legislation. Abbeyfield Ilkley Society Ltd J52 J03 S59448 Abbeyfield V194994 020805 Stage 4.doc Version 1.40 Page 27 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 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 x 3 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 4 3 x 3 3 x 3 Abbeyfield Ilkley Society Ltd J52 J03 S59448 Abbeyfield V194994 020805 Stage 4.doc Version 1.40 Page 28 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. Standard OP9 Regulation 13(2) Requirement The registered manager must ensure that senior members of staff sign or code the medication administration record sheets appropriately. A stock control system is required for medication administered on a prn (as and when required ) basis. The registered manager must ensure that there is a always a senior care assistant on wakeful night duty. The registered manager must review the cleaning staff hours and ensure that they meet the needs of the service. The registered manager must ensure that at least two written references are obtained for all new employees prior to them commencing work. Timescale for action 30/09/05 2. OP27 18(a) 31/10/05 3. OP29 19 30/09/05 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 J52 J03 S59448 Abbeyfield V194994 020805 Stage 4.doc Version 1.40 Page 29 Abbeyfield Ilkley Society Ltd 1. 2. Standard OP22 OP 33 Grab rails should be fitted in all toilet areas to assist the residents. Quality assurance surveys should involve not only the service users, but also their relatives and other stakeholders in the community. Abbeyfield Ilkley Society Ltd J52 J03 S59448 Abbeyfield V194994 020805 Stage 4.doc Version 1.40 Page 30 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Abbeyfield Ilkley Society Ltd J52 J03 S59448 Abbeyfield V194994 020805 Stage 4.doc Version 1.40 Page 31 - 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!