Inspection on 24/10/06 for Abbeywood

This inspection was carried out on 24th October 2006.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Abbeywood 13/06/06

Abbeywood 19/01/06

Abbeywood 10/08/05

Abbeywood 15/09/04

Abbeywood 17/05/04

Abbeywood 17/02/03

Similar services:

The Shelley

Thorndene

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

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

CARE HOMES FOR OLDER PEOPLE Abbeywood Abbeywood Wharf Road Ash Vale Surrey GU12 5AX Lead Inspector Sandra Holland Key Unannounced Inspection 24th October 2006 11:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Abbeywood DS0000013544.V316528.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Abbeywood DS0000013544.V316528.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbeywood Address Abbeywood Wharf Road Ash Vale Surrey GU12 5AX 01252 317132 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) www.anchor.org.uk Anchor Trust Mrs Alexandra Strong Care Home 50 Category(ies) of Dementia - over 65 years of age (21), Old age, registration, with number not falling within any other category (12), of places Physical disability over 65 years of age (15) Abbeywood DS0000013544.V316528.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The age/age range of the persons to be accommodated will be: 65 YEARS AND OVER Up to twenty-one (21) residents may be within the category DE(E) Dementia - over 65 years of age. Up to fifteen (15) residents may be within the category PD(E) Physical Disability over 65 years of age. 13th June 2006 Date of last inspection Brief Description of the Service: Abbeywood is a purpose built home located in the residential area of Ash Vale and is located next door to the local health centre. The Home is managed by the Anchor Homes Trust and is registered to care for 50 residents over the age of 65. A Manager, Deputy Manager and a team consisting of care staff, catering, domestic, administration and maintenance staff are employed to meet the needs of residents. The home is divided into five separate units each comprising of a lounge/dining room with its own kitchen area where refreshments can be provided. Residents are accommodated in single bedrooms that are all close to communal bathroom and toilet facilities. The home has a private, central courtyard garden that is secure and accessible to residents. A limited amount of car parking is available for visitors. The fees at Abbeywood range from £650.00 to £750.00. Abbeywood DS0000013544.V316528.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the second key inspection to be carried out in the Commission for Social Care Inspection (CSCI) year, April 2006 to June 2007 and was carried out under the CSCI “Inspecting for Better Lives” programme. Mrs Sandra Holland, Lead Inspector carried out the inspection over seven hours. Mrs Alexandra Strong, Manager and Ms Michelle Reaney, Deputy Manager were both present representing the home. As the manager had a prior engagement at the time of the inspection, most of the information was supplied by the deputy manager. This second, key inspection was carried out to reassess standards assessed as adequate or poor at the previous inspection, carried out on 13th June 2006. Areas of the home were seen and a number of residents and staff were spoken with during the tour of the home. A selection of records and documents were sampled, including pre-admission assessments, residents’ individual plans, medication records and staff files. CSCI feedback cards were supplied to the home for distribution to residents, relatives and visitors and health care professionals, in order to gather the independent views of those involved in the support of residents. Nine CSCI feedback cards were returned from residents, five from relatives or visitors and three from visiting healthcare professionals. The feedback was very positive and some respondents also made additional, complimentary comments. The people living at the home prefer to be known as residents and that is the term that will be used throughout this report. The inspector would like to thank the residents, staff and management for their time, assistance with the inspection process and for their hospitality. What the service does well: The home is cheerfully decorated, well furnished, presents as a comfortable place to live and has an attractive, enclosed courtyard garden available for residents’ use. Residents spoke highly of the helpfulness and cheerful assistance of staff and staff were observed to interact with residents in a friendly and informal but appropriate way. Abbeywood DS0000013544.V316528.R01.S.doc Version 5.2 Page 6 It is clear that the staff are responsive to changes in residents’ health and seek prompt and appropriate advice. An effective working relationship is held with the local health centre. The management team are clearly committed to providing a quality service at the home and spoke with enthusiasm and eagerness about further plans to improve. What has improved since the last inspection? What they could do better: The working hours of activities staff must be reviewed to ensure they are sufficient to meet the needs of residents, seven days a week. The hours currently worked by activities staff, are less than one hour per resident per week, even though the majority of residents either have dementia or a physical disability. The home’s corporate complaints procedure has been re-issued, but the content remains unchanged and needs to be reviewed and revised to ensure it meets the needs of residents. The entitlement to work in the UK, of any staff or applicants to work at the home, must be established and a record maintained. Records of staff induction must be maintained and retained in the home. Abbeywood DS0000013544.V316528.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Abbeywood DS0000013544.V316528.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Abbeywood DS0000013544.V316528.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. Standard 6 is not applicable at this service. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. An updated copy of the home’s statement of purpose and service users’ guide will be forwarded to CSCI. The needs of all residents are assessed before they move into the home. EVIDENCE: A copy of the home’s statement of purpose and service users’ guide are held on file by CSCI but these are outdated. This was discussed with the deputy manager and it was agreed that updated copies of these would be forwarded to CSCI. The individual plans for a number of recently admitted residents were seen and it was pleasing to see that a thorough pre-admission assessment of the needs of the residents had been carried out. The assessments were very detailed and contained information regarding the residents’ personal histories, needs, likes, dislikes and preferences. Abbeywood DS0000013544.V316528.R01.S.doc Version 5.2 Page 10 For those residents who are supported financially by a local authority, an assessment had been carried out under the care management process. A copy of the care management assessment had been obtained and retained, where applicable. Abbeywood DS0000013544.V316528.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans are well documented and detailed, to effectively guide staff to the care and support needs of residents. Medication appears to be appropriately administered and residents are treated with dignity and respect. EVIDENCE: As stated previously, the care plans of a number of recently admitted residents were sampled. The plans are used to guide staff to the support and care needs of residents, and those seen contained comprehensive and detailed information. It was pleasing to see the improvement in the amount and quality of information in the care plans. It was also noted that residents had signed many areas of their plans to indicate their involvement in drawing it up or to confirm their consent or preferences. Residents had signed to give their consent to staff at the home administering their medication, to state their preference for male or female carers and to confirm whether they wished to have a key for their bedroom. Abbeywood DS0000013544.V316528.R01.S.doc Version 5.2 Page 12 It was noted that photographs of residents were not present in the care plans which were seen. The deputy manager stated that photographs of all recently admitted residents had been taken with a new digital camera and had still to be printed. Any risks to residents that are identified have been assessed, recorded and where possible, minimised. Those seen included assessments of the risks associated with mobility and of getting lost. It was clear from the records seen and speaking to staff and residents that residents’ healthcare needs are well met. A number of healthcare professionals are involved in the support of residents, including general practitioners (GP’s), community nurses, a chiropodist and community psychiatric nurses (CPN’s). The administration of medication appeared to be well managed, with medication appropriately stored and the required records maintained. A locked room is specifically allocated for the storage of medication and is equipped with secure storage cupboards and a lockable fridge for medication requiring chilled storage. Access to medication is restricted to the management team and senior staff and the deputy manager stated that she takes the lead in ordering and receiving medication supplies. The deputy manager advised that following an earlier build up some medications, the stocks were now being reduced. The stocks of medications held were checked with the records held and these accurately matched. Staff were seen to treat residents with respect, speaking in a relaxed and friendly but appropriate manner. Resident’s privacy was promoted, with staff taking care to knock on resident’s bedroom doors before entering and providing personal care in a tactful and discreet way. Abbeywood DS0000013544.V316528.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are offered a range of leisure activities, although the hours worked by activities staff need to be reviewed. Residents are supported to maintain contact with their families and friends and to make their own choices. A wellbalanced diet is provided. EVIDENCE: The deputy manager stated that the activities co-ordinator had been appointed earlier this year, having worked at the home for a number of years in a care role. The activities co-ordinator advised that she and another member of staff who assists with activities, had recently attended a training course which specifically included activities for people with dementia. Both staff said they had found the training course stimulating and inspiring, and had gathered many new ideas to make activities more suited to the needs of people with dementia. These included having very short sessions of activity, and carrying out simple but effective painting and craft ideas, with quickly achieved results. A weekly activities programme has been arranged and was seen displayed in picture format on the unit notice boards. These included in-house activities such as quizzes, arts and crafts, church services, cheese and wine tasting, Abbeywood DS0000013544.V316528.R01.S.doc Version 5.2 Page 14 skittles and “seniorcise” and outings to the local garden centre, to local shops and to other places of interest in the area. It was observed that activities are currently only scheduled for forty hours each week arranged from Mondays to Fridays and this equates to less than one hour per week for each resident. To ensure that the social and cultural needs of all residents are met, including those with dementia or physical disabilities, the hours worked by the activities co-ordinators must be reviewed and should include activities across the whole week. Staff were seen to offer residents choices and to encourage residents to be independent wherever possible. The deputy manager advised that one resident in the home does not speak English, but staff have been supported by the resident’s family to learn a small number of essential words. Staff have come to know the resident’s likes and dislikes and observe the resident’s facial expressions and body language to assess responses. The staff group in the home are culturally and racially diverse, but this is not generally reflected in the resident group. The lunchtime meal which was served on the day of inspection appeared appetising and wholesome. There was a choice of two main courses, both of which were offered to residents to enable them to make a choice. Staff advised that further alternatives, including a salad or filled jacket potato were available to residents, if preferred. Extra portions of food were willingly provide to residents requesting them. Staff advised that specialist diets including those for differing ethnicities can be accommodated, and currently diabetic and pureed diets are provided in addition to the main menu. The pureed diets served to residents were attractively presented, with the individual food items pureed to retain their colour. A requirement has been made regarding Standard 12. Abbeywood DS0000013544.V316528.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are confident that their complaints will be listened to and will be acted on. Staff are aware of their responsibilities in the protection of residents. EVIDENCE: A complaints policy and procedure is available in the home and is supplied to residents in their service user’s guide, the manager stated. The manager stated that the complaints policy on display is the Anchor organisation’s corporate policy which has recently been reissued to incorporate the organisation’s logo. It was required at the previous inspection that the corporate complaints policy was reviewed and revised, but it was noted that the content of the policy had not been changed. It is required that the policy is reviewed and revised to meet the needs of the residents who are all elderly and frail, and many of whom are physically disabled or have dementia. The current policy emphasises the need to write to the organisation with complaints which would not be easy for the resident group to do. From speaking to residents it was clear that they felt able to approach staff or the manager with any complaints or concerns. The manager and deputy manager were both observed to interact with residents in an informal and friendly manner, whilst maintaining respect and dignity. Abbeywood DS0000013544.V316528.R01.S.doc Version 5.2 Page 16 The deputy manager advised of a complaint that had been made since the last inspection, and of the actions taken in response. It was clear that the complaint had been managed appropriately and the inspector had been kept informed of the outcome. The deputy manager stated that regular resident meetings are held and provide another opportunity for residents to air their feelings about the home or to raise any issues. Minutes of a recent residents’ meeting were seen on the unit notice boards. Staff spoken to stated that they would report any concerns they had about the abuse or potential abuse of residents, to the manager or the senior in charge, and would not hesitate to do so. A number of staff advised that they had received training in the safeguarding of adults and in the rights and responsibilities of residents. A requirement regarding Standard 16 has been made. Abbeywood DS0000013544.V316528.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service The home presents as a comfortable place in which to live and was colourful, clean and appeared hygienic. EVIDENCE: Overall the home was seen to be very well maintained and attractively decorated in a range of colours. An enclosed courtyard garden was accessible from a number of areas of the home. The home is arranged as five individual, family-style units, each with their own open-plan lounge/dining room and small kitchen. Residents have single bedrooms which are fitted with wash-hand basins. Toilets and easy access baths are available close to resident bedrooms on each unit. One unit accommodates more dependent residents with dementia. The lounge on this unit was previously noted to be rather bare, so it was pleasing to see Abbeywood DS0000013544.V316528.R01.S.doc Version 5.2 Page 18 that the room had been brightened up by the addition of residents’ own artwork and photographs of resident events which had taken place during the summer months. A range of stimulating items have been made by residents, or provided, to create interest and topics of conversation and a television and a music system were available for residents to enjoy. The deputy manager advised that plans are being developed to incorporate the separate lounge and dining room on this unit into one room, by creating an archway between the two rooms. This will enable residents to see what is happening in both rooms and will create a bigger space in which to carry out activities. Staff also advised that an allocated “Qualia” sensory room on the unit was rarely used as it was not very accessible. It is anticipated that the beneficial elements of the sensory room, including the coloured lights and soothing images, will be moved to the lounge for the enjoyment of all residents. All areas of the home were very clean and tidy and appeared hygienic. Handwashing facilities with liquid soap and paper towels are provided in all appropriate places and staff were seen to use these. Staff were also observed to use personal protective equipment, including aprons and gloves, to prevent the spread of infection. The laundry is situated at the front of the building at the end of a unit corridor and is away from food preparation and serving areas. It is well equipped with the appropriate facilities and is staffed by an allocated member of laundry staff. Abbeywood DS0000013544.V316528.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A full complement of staff are employed to meet residents’ needs. Recruitment practices in the home have improved with only one shortfall noted. Staff receive training appropriate to their role. EVIDENCE: From the information provided, it was clear that a full team of staff are employed to meet all the needs of the residents. These include care staff, kitchen staff, housekeeping staff, laundry staff, a handyperson/gardener, an activities co-ordinator, receptionists and administrators. The information provided during the previous inspection confirmed that a number of care staff have achieved National Vocational Qualifications (NVQ), to level 2 or higher. As nine staff have achieved this and a further eight are undertaking this, the home continues to work towards the recommended fifty per cent of qualified staff. It was pleasing to note an improvement in the recruitment practices at the home. The files of a number of recently recruited staff were seen and the required recruitment records and documents had been obtained. It was observed that for two members of staff, no confirmation of their entitlement to work in the UK had been obtained. The deputy manager stated that she had seen updated documents for one of the members of staff, confirming that they were entitled to work, but had not taken copies of the documents. The deputy Abbeywood DS0000013544.V316528.R01.S.doc Version 5.2 Page 20 manager stated that she would request the member of staff to bring these in for copying and retaining, and would ask the other member of staff to provide documentation to confirm their entitlement to work. Individual staff training records are maintained and these were seen to record the training undertaken by each member of staff, including fire safety, first aid, moving and handling and infection control. A comprehensive induction record has been produced by Anchor and a copy of this was seen for a recently recruited member of staff. The induction training records for two other new members of staff were not available for inspection. The deputy manager stated that staff take the records to update them and may have taken them home. These must be retained in the home and made accessible to staff there. This will prevent any loss and ensure that these records are available for inspection, as required. Requirements regarding Standards 29 and 30 have been made. Abbeywood DS0000013544.V316528.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is effectively managed by a person who is fit to be in charge and is run in the best interests of the residents. Residents’ financial interests are protected by the home’s policies and procedures and the health and safety of residents is promoted. EVIDENCE: The manager’s application to be registered by CSCI has now been completed and it is clear that the manager is fit to run the home. The manager has many years experience in care, was previously a deputy manager at another Anchor home and has carried out a support manager role within Anchor homes. The manager is ably supported by an effective deputy and a number of senior care staff, providing a strong management team. It was pleasing that all senior Abbeywood DS0000013544.V316528.R01.S.doc Version 5.2 Page 22 staff spoken to conveyed enthusiasm and commitment to providing a high quality of service at the home. The deputy manager advised that a feedback form titled “How are we doing ?” has been developed and has been supplied to a number of residents and visitors since the last inspection. Fourteen of these had been received back from residents and ten from visitors, the majority with positive responses and comments. A selection of CSCI feedback cards were also supplied to the home for distribution to residents, healthcare professionals and visitors. Nine CSCI feedback cards were returned from residents, five from relatives or visitors and three from visiting healthcare professionals. It was pleasing that the feedback was very positive and some respondents also made additional, complimentary comments. Those received from healthcare professionals indicated that the home manages residents’ medication appropriately, that specialist advice is incorporated into residents’ care plans and that the home works well with, and communicates with the respondents. All three healthcare professionals indicated that they were satisfied with the overall care provided to residents. The administrator advised that monies are held for safekeeping for a number of residents. To safeguard residents’ finances, only administrative or senior staff have access to these and two signatures are recorded for each transaction. Residents are also provided with a lockable facility in their bedrooms, in which to store any valuables. During the tour of areas of the home, no hazards to the health or safety of residents were observed. Two requirements regarding health and safety in the home, which were made at the last inspection carried out on 13th June 2006, have been met. These were that doors designed to close when the fire alarm is activated must not be wedged open, and that products hazardous to health must be stored in a locked cupboard. From information supplied, it is clear that the required maintenance and checks on systems and equipment in the home, are carried out to the required frequency, to promote the safety and welfare of all who live and work at the home. Abbeywood DS0000013544.V316528.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Abbeywood DS0000013544.V316528.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes 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 OP12 Regulation 18 Requirement Having regard to the size of the home, the statement of purpose and the needs of residents, sufficient staff must be employed, as are appropriate for the health and welfare of residents. Specifically, the hours worked by activities staff must be reviewed to ensure they are sufficient to meet the social and cultural needs of all residents. The home’s corporate complaints procedure must be reviewed and must be suited to the needs of the residents. Timescale of 08/09/06 not met. Persons must not be employed to work at the care home unless they are fit to work at the care home. Specifically, the person’s entitlement to work in the UK must be established and documentary evidence of this obtained and retained in the home. Staff must receive induction training appropriate to the work they are to perform and a record of this must be maintained and DS0000013544.V316528.R01.S.doc Timescale for action 26/01/07 2 OP16 22 26/01/07 3 OP29 19 24/10/06 4 OP30 18 21/11/06 Abbeywood Version 5.2 Page 25 retained in the home. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Abbeywood DS0000013544.V316528.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Abbeywood DS0000013544.V316528.R01.S.doc Version 5.2 Page 27 - 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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