Inspection on 31/01/06 for Abbeymoor Care Home

This inspection was carried out on 31st January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Abbeymoor Care Home 17/09/09

Abbeymoor Care Home 28/11/08

Abbeymoor Care Home 30/06/08

Abbeymoor Care Home 27/07/07

Abbeymoor Care Home 19/10/06

Abbeymoor Care Home 16/08/05

Abbeymoor Care Home 19/10/04

Abbeymoor Care Home 21/04/04

Similar services:

Trevayler Residential Care Home

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

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

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Abbeymoor Care Home Sherwood Road Worksop Nottinghamshire S80 1QW Lead Inspector Karmon Hawley Unannounced Inspection 31st January 2006 10:00 X10029.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 Abbeymoor Care Home DS0000059941.V281868.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 and Care Homes for Adults 18 – 65*. 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. Abbeymoor Care Home DS0000059941.V281868.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Abbeymoor Care Home Address Sherwood Road Worksop Nottinghamshire S80 1QW 01909 475660 01909 480998 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) Care Companions Healthcare Ltd Ms Rita Mason Care Home 25 Category(ies) of Dementia - over 65 years of age (19), Mental registration, with number disorder, excluding learning disability or of places dementia (6), Old age, not falling within any other category (19), Physical disability over 65 years of age (19), Terminally ill (19) Abbeymoor Care Home DS0000059941.V281868.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4 of the beds may be used for service users over the age of 60 years There will be a Lead, Head of care, for the eating Disorders unit on site between the hours of 08:00 and 18:30 MD Category can only be used for Younger adults (Eating Disorder) age 18 to 65 16/08/05 Date of last inspection Brief Description of the Service: Abbeymoor is a care home that provides residential/nursing and specialist care to adults form the age of eighteen. There are 25 places and services are offered to both female and male residents. The care home is registered to provide specialist care and support for up to 6 adults between ages 18 – 65 with a diagnosed ‘Eating Disorder’ and 19 beds for the older person. The home can offer short term and long term care. It is located close to the shops and local amenities (approximately 500metres). Abbeymoor is a detached building set in its own grounds with a care park to the front of the building. The building is adapted to cater for the needs of people with mobility problems and all areas of the home are accessible. The younger adults unit has it own kitchen, dining room and lounge separate from the communal facilities offered to service users residing within the main building of the care complex. Abbeymoor Care Home DS0000059941.V281868.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 in three hours and was performed by one inspector. The main method of inspection was case tracking, this is a method of sampling the records of three randomly selected service users to ascertain if the needs of service users are appropriately assessed and identified needs are being catered for by the home to maintain optimum health and wellbeing of the service user. Four service users were spoken with and so as to give the inspectors an insight into the conditions and standards within the home. Those spoken with were happy with the staff, care received and the standards within the home. The acting manager assisted in the inspection process and two members of staff were spoken with. Staff were able to demonstrate a good understanding of service users needs and the core values and principles in relation to their job role. The current occupancy of the home was 18 older person service users; the younger adult unit was at this time empty. The focus of this inspection was to concentrates on the remaining core standards not assessed and the requirements made at the previous inspection. What the service does well: Service users spoken with expressed they were happy with care received; one stated it was a beautiful home and offered a good service. They also stated that staff were kind and respectful and tended too needs appropriately. A clam and caring ethos was prevalent throughout the home and staff were observed to interact well with service users. Although additional mandatory training is required for some staff the training programme is varied and over 50 of staff have attained or are working towards the national vocational qualification. Training is also specific to the relevant job role enhancing current care practices. Abbeymoor Care Home DS0000059941.V281868.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Reviews with regards to care plans take place, however these are to be service user focussed to reflect care and current conditions thus ensuring up to date information is available. Risk assessments have developed, however further attention is required to ensure all identified needs are addressed Staff are to be trained in all mandatory areas to ensure they individually and collectively have the knowledge and skills to fully meet service users needs Social assessments require further attention to ensure service users needs are identified and thus met. Further assessments and documentary evidence is required to demonstrate service users have been consulted with regards to chairs, ensuring these are appropriate to needs. Further attention is required with regards to the risk assessment of the laundry to fully protect staff. Further attention is still required to the maintenance of the home to ensure service users live in a well-maintained environment. Fire alarms are to be tested on a weekly basis to ensure service users are protected. Attention with regards to the administrator acting as an agent for one service user is required to ensure both are fully protected. A requirement set at the previous inspection with regards to the ensuite toilet between rooms 6 and 7 on the younger adults unit is to be further researched Abbeymoor Care Home DS0000059941.V281868.R01.S.doc Version 5.1 Page 7 by the inspector to ascertain specific requirements and actions to be taken; the provider will be liaised with following this. 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. Abbeymoor Care Home DS0000059941.V281868.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Abbeymoor Care Home DS0000059941.V281868.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 Prospective service users have the information they need to make an informed choice about where to live. EVIDENCE: The statement of purpose has been updated to include the current registration of the home and the commission for social care inspection details. Abbeymoor Care Home DS0000059941.V281868.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards to be inspected at least once during a 12 month period JUDGEMENT – we looked at outcomes for the following standard(s): 7,9,10 Service users individual needs are set out in a plan of care, however reviews are not service user focused in all instances therefore this may affect care delivered, consequently needs may not be fully met. Service users are protected by the homes policies and procedures with regards to medication, however further consideration is required when service users are self administrating to ensure all risks are identified and reduced as far as reasonable practicable. Service users privacy and dignity are respected and upheld. EVIDENCE: Abbeymoor Care Home DS0000059941.V281868.R01.S.doc Version 5.1 Page 11 Service users undergo various assessments with regards to the activities of daily living, mental health and cognition, nutrition, manual handling, social interests, infection and dependency. Information gained forms the basis of the plan of care; within two files observed the social assessment had not been completed. Care plans in place were personalised and reflected care required. Reviews were observed to take place, however in the main these were not service user focused and did not reflect care and condition, ensuring up to date information was available in all cases. Daily records were maintained and recorded significant events. Risk assessments were in place and contained required information; however further risk assessments are required with regards to the use of bed rails and the risk of entrapment and when service users are self-administrating medication. There was evidence of service users and relatives input and that consultation with regards to care had taken place. There was also evidence that the multidisciplinary team are liaised with as required. Service users spoken with stated their needs were met and they were happy with care received. Staff were able to discuss the core values and principles and the needs of service users. There is currently one service user who is self-administrating medication, appropriate facilities are in place and staff support and offer guidance as required. This is recorded on the medication administration chart, however a risk assessment with this regard was not in place. All staff are instructed with regards to maintaining privacy and dignity during the induction process and the national vocational qualification. Service users spoken with stated that staff are respectful and privacy is maintained. Visitors and consultations may take place in private if required. Screening is available in shared rooms; two service users spoken with were able to substantiate this. A payphone is available for service users use. Staff spoken with were able to discuss how privacy and dignity would be maintained. Abbeymoor Care Home DS0000059941.V281868.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13,14 Service users are helped to exercise choice and control over their lives and are enabled to maintain relevant contacts as they wish. EVIDENCE: There are no restrictions on visiting and one visitor was observed to enter the home by using the code for the keypad, thus enabling easier access. The visitor’s policy is discussed prior to service users entering the home and is also stated in the statement of purpose and service user guide. There are no links with the local community at present, however the acting manager stated this Abbeymoor Care Home DS0000059941.V281868.R01.S.doc Version 5.1 Page 13 was due to service users need and preferences and should this change this situation would be reviewed. There is currently one service user who deals with his own finances; there are lockable facilities available to ensure safety. One service user spoken with stated that he went out regularly and took care of his own personal allowance. There is also the facility to keep an account at the home to aid access to personal allowances. There are no advocates used at present, however the acting manager stated that these would be accessed of required. Service users are able to bring in personal possessions should they wish, two service users spoken with substantiated this and expressed that they were very happy with their rooms. Within case files examined social assessments were in place, however only one had been completed and only two service users had a plan of care in place with this regard. The acting manager stated that service users have been consulted with, some service users do not wish to join in activities whereas other do so. No written evidence of this was available, however service users spoken with stated that they join in games and have the occasional trips out, one service user often visits the town, whereas another did not wish to join in activities and is happy looking out of the windows. Abbeymoor Care Home DS0000059941.V281868.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 Service users and their relatives may be confident that their complaints will be listened to, taken seriously and acted upon. EVIDENCE: An appropriate policy with regards to complaints was observed to be in place. There have been no complaints received since the previous inspection. Staff spoken with were able to discuss how complaint would be dealt with should they be received. Service users spoken with expressed no concerns. Abbeymoor Care Home DS0000059941.V281868.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Whilst service users live in a safe and satisfactory maintained environment improvements are required to raise the standard. The home is clean, pleasant and hygienic, however further work in the laundry room is still required to improve the standard and bring it in line with current legislation. EVIDENCE: Abbeymoor Care Home DS0000059941.V281868.R01.S.doc Version 5.1 Page 16 The downstairs toilets and bathroom have been redecorated to make them more homely; the bath is not used due to the current needs of service users. Further redecoration is required throughout areas of the home. The laundry room still requires repair to the plaster on the walls, the acting manager stated this has been taking place and further work is planned. Gas force have serviced the main boilers and stated that further ventilation is required; this area is very warm; the acting manager stated this is currently being arranged. Abbeymoor Care Home DS0000059941.V281868.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28,30 Service users are in safe hands and staff undertake a varied training programme, however to ensure service users needs are fully met further attention with regards to mandatory training is required. EVIDENCE: Six members of staff have attained the national vocational qualification level two, three have commenced this training and three members of staff are looking to start level three. The acting manager achieved the Registered Managers Award in May 2005. There are two separate induction packs specifically for each unit within the home, evidence of which were available within staff files observed. Staff training that takes place covers a variety of issues relevant to each unit such as nutrition in the care setting, dementia and protection of vulnerable adults. Mandatory training takes place, however not all staff have completed all areas. One staff member spoken with had received in house training covering mandatory areas since commencing employment five months ago, Abbeymoor Care Home DS0000059941.V281868.R01.S.doc Version 5.1 Page 18 however no outside training had been received. All staff are due to undertake an update in fire training and the acting manager stated this was booked for the end of the month. Staff had completed questionnaires to demonstrate competence. No official manual handling training other than in house is offered at present. Colleges and free training is used in addition to part funded courses. The acting manager has attended various courses along with the registered nursed which are specific to their job roles. Staff stated they felt supported in their development and they were able to discuss relevant issues and the needs of service users. Service users spoken with stated that staff were kind and caring, assisted to needs appropriately and these were met. Abbeymoor Care Home DS0000059941.V281868.R01.S.doc Version 5.1 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33,35,38 The home is run in the best interest of service users. Improvements to the procedures used for handling service users personal finances have improved, thus enhancing the security of this, however further consideration with regards to the administrator dealing with one service users finances is to be reviewed to ensure both staff member and service user is fully protected. Abbeymoor Care Home DS0000059941.V281868.R01.S.doc Version 5.1 Page 20 Fire tests are improved, however are still required to be carried out on a weekly basis to fully protect service users. EVIDENCE: The acting manager has now submitted an application to the commission for social care inspection in order to become the registered manager. Questionnaires are given to service users and relatives on a six monthly basis; these differ on each occasion and are related to the care, environment, food, domestic and general issues. Evidence of completed questionnaires was observed and demonstrated satisfactory responses. Should negative responses be observed, if more than one has brought this to attention then the matter is addressed and information and responses to this is displayed in the notice board. If a matter is on an individual basis then this is addressed with the individual person involved. The acting manager stated that the proprietors have an annual development plan in place, which involves the refurbishment of the home, however this was not available for inspection. The manager stated she supports these plans and also has her own development plans with regards to continuing the upgrading of the home, staff training and development. The acting manager and proprietors review and update policies and procedures on an annual and as required basis. Service users spoken with stated that staff listen to their needs and act upon them. The procedure with regards to personal allowances has undergone change; each service user now has individual wallets and accounting sheets. Records of all transactions were maintained and three service users accounts were checked and found to be correct. Receipts were also in place for any purchases made. There was evidence of audits taking place. The administrator although not an appointee for a service user under his instruction advocates and draws his money from his post office account to pay his fees. On observing fire records, fire drills have not been tested on a weekly basis. The acting manager stated this is due to the maintenance man being on annual leave and so fire drills and tests can be done on differing days so all staff are involved. Staff have completed fire awareness questionnaires to demonstrate their understanding. Abbeymoor Care Home DS0000059941.V281868.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 3 2 X 3 X 4 X 5 X 6 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X ENVIRONMENT Standard No Score 19 2 20 X 21 X 22 X 23 X 24 X 25 X 26 2 STAFFING Standard No Score 27 X 28 3 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No Score 31 X 32 X 33 3 34 X 35 3 36 X 37 X 38 2 Abbeymoor Care Home DS0000059941.V281868.R01.S.doc Version 5.1 Page 22 Yes 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 OP7 Regulation 15(2,b) Requirement Timescale for action 03/03/06 2 OP7 13(4,c) 3 OP12 16 4 OP19 23 Service users reviews are required to be service user focused to reflect care and current condition to ensure needs are fully met. All identified risks such as the 03/03/06 use of bedrails and selfadministration of medication is required to have a risk assessment in place. The registered person must 03/03/06 consult with residents about their programme of activities and provide facilities for recreation having regards to the needs of residents. This has been explored and partly met, however further consideration is required to ensure this is documented and all assessments are completed. The registered person must 07/02/03 ensure the home is kept in a good state of repair both internally and externally and reasonably decorated. This has been partly met and the ground floor toilets have been redecorated, however further work is now required and a DS0000059941.V281868.R01.S.doc Version 5.1 Abbeymoor Care Home Page 23 5 OP24 16 6 OP26 23 7 OP30 18(c) 8 OP35 20(3) 9 OP38 23(4,c,v) development plan is to be submitted to the commission for social care inspection to evidence how this requirement will be complied with. The registered person must provide chairs in residents’ rooms to meet the need of resident. This has been partly met, service users have been liaised with and evidence was available within two case files, some chairs have been replace, further documentary evidence is now required to fully meet this requirement. Complete a risk assessment on the laundry and record the outcome and action. This has been partly met, however further consideration with regards to the ventilation and the stairs is to be included. Staff are to be fully trained in all mandatory areas to ensure they have the individual and collective knowledge and skill to meet service users needs. The registered person shall ensure as far as practicable that persons working at the care home do not act as agents of a service user. The registered person must ensure that fire tests and records are maintained and up to date. This is an outstanding requirement and must be addressed to avoid enforcement action. 03/03/06 14/02/06 03/04/03 03/04/03 31/01/06 Abbeymoor Care Home DS0000059941.V281868.R01.S.doc Version 5.1 Page 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Abbeymoor Care Home DS0000059941.V281868.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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. Abbeymoor Care Home DS0000059941.V281868.R01.S.doc Version 5.1 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. 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