Inspection on 05/03/07 for Abbots House

This inspection was carried out on 5th March 2007.

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

Abbots House 27/04/06

Abbots House 10/01/06

Abbots House 10/08/05

Abbots House 06/12/04

Abbots House 29/06/04

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

CARE HOMES FOR OLDER PEOPLE Abbots House 103 Abbots Road Abbey Hulton Stoke on Trent Staffordshire ST2 8DJ Lead Inspector Mr Berwyn Babb Key Unannounced Inspection 5 March 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Abbots House DS0000028862.V312938.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. Abbots House DS0000028862.V312938.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbots House Address 103 Abbots Road Abbey Hulton Stoke on Trent Staffordshire ST2 8DJ 01782 234888 01782 232938 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) Stoke on Trent City Council Miss Melanie Joy Fenton Care Home 39 Category(ies) of Dementia (5), Dementia - over 65 years of age registration, with number (39), Mental Disorder, excluding learning of places disability or dementia - over 65 years of age (6), Physical disability over 65 years of age (39) Abbots House DS0000028862.V312938.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 5 Dementia (DE) - Minimum age 55 years on admission Date of last inspection 27 April 2006 Brief Description of the Service: Abbots House is a Local Authority older people’s home that provides care for 39 older people who have dementia, a physical disability, or other mental health problems that are neither dementia nor learning disability. The home is operated by Stoke-on-Trent Social Services, and additionally has three beds to provide short-term care. There is an attached day centre that caters for a maximum of 25 people and some of the residents of Abbots House like to spend time in the day centre, enjoying the activities and the stimulation that this provides. Located in Abbey Hulton, the home is a two-storey property providing all single bedrooms There are four separate living areas, each having a lounge-dining room, with adjacent bedrooms, bathroom and toilets. First floor accommodation is generally accessed by the passenger lift. For emergencies and for service use, there are enclosed staircases at either end of the building. Externally there is a car park and the rear garden offers an enclosed area for residents. The location of this home ensures that there is a wide range of community facilities nearby that can be readily accessed. Abbots House DS0000028862.V312938.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This second key inspection for the current year was carried out on the afternoon and early evening of Monday 05/03/07, and commenced with the discussions with the care manager about the focus on purpose of the visit. In line with current CSCI policy, all homes were major concerns had been identified at the previous inspection are receiving a second key inspection, and the care manager was informed that unless other major concerns became apparent, this inspection would focus on whats been done to address the issues recorded in the report of 27/04/06, touching only lightly on other areas. The majority of the concerns previously expressed had been in relation to issues identified by the Staffordshire Fire and rescue service, and a letter from them dated 05/12/06, stated that all these issues had now been satisfactorily addressed. Other areas of concern had related to the quality of recording in care plans, and this was found to be much improved Information for this report was taken from discussion with the care manager, from a formal interview with a member of staff, from observation whilst in the home, from chatting to residents, and from a review of rotas, care plans, and other documents. The home was warm and clean and free from odour, and the staff were seen to be into acting with, and responding to, residents, in a way that displayed a high degree of empathy, particularly with those who had Dementia. The current range of fees quoted by Stoke city councils social service departments, commence at £328 per week, rising to a maximum of £710 per week. What the service does well: This home continues to provide an appropriately staffed refuge for older people who have dementia and other mental health needs, in a location that is easily reached by public transport, and close to business, social, and health facilities, whilst being situated in the heart of a local residential area. Abbots House DS0000028862.V312938.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? Since the last inspection Staffordshire Fire and rescue service have written to the home expressing their satisfaction with the work that has been carried out to meet the requirements they previously indicated as being necessary to meet the health, safety, and welfare, of the residents of the home. There has been an improvement in the standard of recording in care plans. Quality questionnaires have been issued, collected, and then collated into a documentary record, of how resident’s wishes and feelings can be considered during the provision of the service. Steps have been taken to increase access to resident’s bedrooms during the daytime. The majority of staff (90 ) have now received vulnerable adult training, and the appropriate Department of Health P O. V. Guidelines have been made available to all staff, with copies being kept in the office. Care management assessments have been undertaken on all residents admitted since the last report, and copies of these appear in the care plans. Resident’s weights have been recorded regularly, and this information has been noted in their care plan. Members of staff have received further instruction on the importance of only using personal protective equipment once, and then discarding it. Copies of inspection reports and other helpful information, have been made available in the newly created Resource Room. Procedures have been put in place to ensure that staff escort residents wishing to smoke to the appropriately designated area, and then see that the door is kept shut, so that the smoke exit through the extractor fans, and does not impinge upon the rest of the home. The CSCI report Highlight of the Day has been made available to all staff. This has been found helpful in producing appropriate finger foods for those residents who have dementia. As a result of opinions expressed in the questionnaire, meetings have taken place with relatives who had identified ways in which the service could be improved, and they are now being more fully involved in taking these ideas forward. Posters indicating the correct colour coding for mops and buckets have now been displayed in the laundry, domestic storage areas, and the kitchen. Abbots House DS0000028862.V312938.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Abbots House DS0000028862.V312938.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 Abbots House DS0000028862.V312938.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): 3, and 6. Quality in this outcome area is good. This judgment has been made using all available evidence including a visit to the service. Recently admitted residents had received robust pre-admission assessments both by a member of the senior management of the home, and under care management procedures using a Single Assessment Process protocol, and contracts were also seemed to conform to Minimum Standards. EVIDENCE: The inspector was shown a care plan on which there was a copy of the contract, and the manager reported that were contracts had been agreed and signed on behalf of the resident by a relative, advocate, or other appointed person, these were deposited in the safekeeping at the providers headquarters. Abbots House DS0000028862.V312938.R01.S.doc Version 5.2 Page 10 The sample contract that was seen met all the minimum standard requirements, and in this and other care plans seen during the afternoon, recently admitted residents had all received a robust assessment of their needs, and recording of their known or expressed personal choices, price and coming into the home. Documents included both the assessments used by the home, and those used in the Single Assessment Process which is undertaken by different agencies in this area, and furthermore showed that the initial assessment by the home had taken place where ever the prospect of resident was at that time, (more often than not this being on a hospital ward). Intermediate care as defined in National Minimum Standard No 6, is not provided in this home. Abbots House DS0000028862.V312938.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, 10, and 11. Quality in this outcome area was good. This judgment has been made using all available evidence including a visit to the service. There were appropriate care plans detailing the health and personal care needs of the residents, and their individual wishes, including details of how these were to be met. Procedures for the administration and handling of medication had previously been shown to be appropriate. Improvements have taken place in the environment to enhance the courtesy and dignity of residents. Sensitivity was observed in the planning recorded for a resident demise and funeral. EVIDENCE: The care plans of four residents were examined closely, and others less so. They were found to detail the social and health care needs of the residents, and then known and expressed personal choices. Abbots House DS0000028862.V312938.R01.S.doc Version 5.2 Page 12 The input of various professionals had been identified, both for advice and the provision of individual treatment, and in addition to the support of the psycho geriatrician, community psychiatric nurse, diabetes adviser, dietician, physiotherapist, and occupational therapists input was recorded from chiropodists, dentists, opticians, hearing specialists, and an adviser on sign language. Procedures for the administration medication were observed to be sensitive and appropriate on the previous inspection, with suitable training for designated staff, and this area was not re-examined during this inspection. New doors had been fitted to resident’s rooms as part of the work to upgrade their home to meet fire service requirements, and these were all fitted with an appropriate style of locks that would allow residents to have their own key. One resident showed the inspector her room and stated that she was greatly relieved to be able to lock the door when she left, as she said she had previously found other residents in a room, and that she did not like that. The care manager spoke about the steps that are being taken to comply with the requirement of the previous report to improve the access of residents to their rooms, and said the risk assessments had been carried out (as seen in some of the care plans reviewed) and where a resident was not identified as being able to benefit from having their own key, consultation has taken place, including with advocates and families, and as a result of which the doors of some peoples rooms remained locked, in line with the consensus of what their wishes would be if they had been able to understand the implications of the question. The families of other people had asked for the doors to be left open, and had confirmed in writing that they felt this was more acceptable, even though they were aware of the risks to personal property that were entailed as a result of the behavioural problems of some of the other residents. A formal interview took place with a member of the care staff, during which she demonstrated both sensitivity and empathy, and an appreciation of the need to protect the privacy and dignity of a resident who was an able to advocate of these things for herself. This was particularly so during her description of a personal care task, such as bathing a resident. In one of the care plans reviewed, full details of what that persons wishes would be in respect of procedures surrounding their death and disposal were sensitively recorded. Abbots House DS0000028862.V312938.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 of its outcome area is good. This judgment has been made using all the available evidence including a visit to the service stop Residents (especially those with dementia) were seen to be helped to exercise choice over what they did during the day. They were recorded as receiving input from their family and friends, and one man commented upon, and others were seen to be receiving, an appealing and nutritious diet. EVIDENCE: Discussion with the care manager revealed that some outings had been arranged, and that some of the residents attending the day centre within the home, would often go with a carer to the nearby newsagent to purchase daily papers to keep them informed about current affairs, and as a basis for discussion. Others were said to enjoy visiting local food shops. One man was having little naps on a comfy settee, rather than being isolated in his bedroom. Two ladies were sitting on a less comfortable seat near the main entrance, but one that gave them the opportunity to both observe and Abbots House DS0000028862.V312938.R01.S.doc Version 5.2 Page 14 comment on everybody who visited the home, or used the office. There was evidence of outside entertainers visiting the home to provide musical interludes, and of staff with in the home trying to replicate an evening out by devoting Saturday nights to time of music and chat, and an opportunity for residents to enjoy a modest drink . Record showed the input of families into the lives of residents, though on this occasion no visitors to the home were free to speak to the inspector. The care manager spoke about the introduction of real pictures in care plans and other documents to give residents a better understanding of the choices they were being offered in respect of the activities of their daily lives. During a tour of the environment she pointed to where the names of occupants had been written directly onto the aluminium holders on my bedroom doors, because the card or paper insets with their names on that these had been designed to hold, had not survived the attention of some of the more confused residents long enough to be of any use as a reminder to the person who occupied the room. The appropriateness of the appetising diet provided to the residents, including the input of specialist dietary advice when this was needed, was reported upon after the previous inspection of 27/04/06. This area was not fully explored during this inspection, though it was observed that there had been a hot meal available at lunchtime, and to residents had commented favourably on this, especially the desert. When the trolleys were taken down to the lounges at teatime, in addition to warm drinks and sandwiches, there was also a large tray of chips for the enjoyment of residents. Menus provided by the care manager showed a wide variety including local and seasonal foods, and an alternative where residents did not want the first choice. Abbots House DS0000028862.V312938.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 was good. This judgment has been made using all the available evidence including a visit to the service. Residents were seen to be protected by adequate measures to respond to complaints, and by staff who had been recently refreshed in all aspects of the protection of vulnerable adults EVIDENCE: The procedure for making a complaint was on display just inside the front door of the home, and it was confirmed that no complaints had been received by the home during the current inspection period, and none have been received by CSCI either. The home keeps a grumbles book, but none of the things recorded in this would have constituted a formal complaint, and they have all been dealt with at source by members of the home. Where a concern had been raised through the medium of the questionnaires sent out to relatives, the care manager was able to show that this had been used to improve the service, and also to engage that relative in having more say in that part of the running of the home that affected his family member. Abbots House DS0000028862.V312938.R01.S.doc Version 5.2 Page 16 A formal interview was undertaken with a member of staff during which the subject of abuse was covered in full. She correctly identified all people from whom vulnerable adults at Abbots house were at risk (anybody and everybody), what sort of things constituted abuse, and what procedures she should follow if ever she suspected that someone was being abused. She was able to confirm the accuracy of the staff training register shown to the Inspector by the care manager, that 90 of staff had recently received further training sessions on Abuse Awareness. Abbots House DS0000028862.V312938.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, 20, 25, and 26. Quality in this outcome area was good. This judgment has been made using all the available evidence including a visit to the service. The environment was well maintained and appropriately sited, comfortable throughout, and clean and hygienic. EVIDENCE: The outstanding issues relating to environment raised with CSCI by the fire authority are stated in their letter of 05/12/062 now be addressed to their satisfaction. Abbots House DS0000028862.V312938.R01.S.doc Version 5.2 Page 18 Many of the other environmental issues that were raised by the inspector in the last report, have also been addressed during the work undertaken to satisfy the fire officer. Thus the issue of appropriate locks on residence bedroom doors was resolved when the doors themselves were replaced, and concerns about the limiting of access to residents bedrooms had been resolved through the provision of keys to those residents with a capacity to understand their significance and make use of them, and to risk assessment and wider discussion with the familys/supporters of those Residents who lacked this capacity. Very positive comments were made about resident’s personal and communal space in the last report, and only very fleeting reference has been made to them during this inspection. Those areas of the homes seen were felt to comply with National Minimum Standards, and the provision of a Resource Room was felt to be a particularly creative solution to the problem of displaying information in a home where many of the residents (through no fault under their own control) habitually removed, hoarded, or destroyed, posters, leaflets, or any other written information. The intention of the care manager to further equip this room with tea and coffee making facilities for the use of visitors, is also worthy of praise. The care manager was concerned about vandalism was taken place in the area where the sensory garden had been created, and in addition to replacing plants that had been uprooted, and decorative items such as bird tables and bird bath that had been damaged, she proposed to have the fencing heightens from its current level (which was designed to ensure that a frail and elderly resident did not leave the premises and observed) to one that would ensure that unwanted, and younger and more agile persons, could not trespass on the premises. A walk round the whole of the interior of the home was undertaken without seeing anything to cause concern about the safety or welfare of residents, or to question the programs in place to keep the home clean and warm, and to manage the continence needs of residents. Abbots House DS0000028862.V312938.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, on 30. Quality of this outcome area was good. This judgment was made using all the available evidence including a visit to the service. Residents were seen to benefit from an appropriate number, and suitable mixture, of sufficiently trained staff, who had been recruited using proper policies and procedures, and who were aware of how to respond to the diverse needs of the residents of this home. EVIDENCE: There were several areas of concern identified in the last report, and these were examined in detail. It was established that 90 of staff had received training in the protection of vulnerable adults since that time, and also in abuse awareness. Further there was a very high percentage of staff qualified to NVQ level 2 or above, lacking only one of the night time carers, and two of those employed during the day. Abbots House DS0000028862.V312938.R01.S.doc Version 5.2 Page 20 The carer who was interviewed confirmed the extent to which mandatory training, and that more specialised because of the diversity of the needs of residents of this home, had been given and was further planned, and the care manager was able to show a master matrix detailing when every person in the home received a piece of training, and at what time this training would expire and need to be renewed. Observation of the training records of several members of staff identified recent input in the following areas: The protection of vulnerable adults; Risk assessment training; General health and safety awareness; British sign language awareness; Dementia awareness; Funeral awareness; Of the management of Actual and Potential Aggression (MAPA); Injection control (for diabetes care); Awareness of violence and aggression; First Aid at work. As indicated above, there was a matrix of everybodys training needs, and how these will be fulfilled this year, and in 2008. During this inspection nothing was seen to suggest that there were not sufficient staff on duty, to meet the known and emerging care needs and personal choices of the residents, and rotas provided by the care manager showed a normal staffing arrangements to be as follows: 8 a.m. until 3 p.m. five members of care staff and between one and three managers 3 p.m. to 10 p.m. four members of care staff and between one and three managers. 10 p.m. to 8 a.m. three staff awake and watchful, and one manager on sleeping in duty. The rota showed, and the care manager confirmed, that she undertakes a variety of shifts, so that she is able to keep in touch not only with different members of the staff, but also to be able to see residents at different times during the day, and to be available for visiting families. She stated that in order to meet the assessed needs and choices of her residents in the manner that she felt protected their safety and welfare, she regularly had to sanction 70 hours a month bank or agency staff time. She was unable to give an explanation as to why the providers were not making proper regular provision for the needs of the residents in their staffing hours. (It would be more beneficial to the residents to have permanent staff, as it would reduce the number of times they were exposed and familiar faces.) Abbots House DS0000028862.V312938.R01.S.doc Version 5.2 Page 21 In a formal interview undertaken with a member of staff, it was confirmed that during the process of her being recruited all the correct procedures had been followed, including those designed to protect residents by the provision of clear police checks and two written references, and she further confirmed that the protocols followed had met the requirements to operate an equal opportunities policy that allowed for the many diversities of prospective employees. Abbots House DS0000028862.V312938.R01.S.doc Version 5.2 Page 22 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, on 38. Quality of this outcome area was good. This judgment was made using all the available evidence including a visit to the service. The person in charge of the home had previously been registered as a Fit Person, and had many years experience in the management of homes for the elderly, and further nothing was found to suggest any compromise on health, safety, welfare, and the financial best interest, of any resident. EVIDENCE: The providers addressing all those issues raised by the fire officer, and by the last CSCI inspection officer, had robustly improved the health and safety and welfare of residents since the last inspection. Abbots House DS0000028862.V312938.R01.S.doc Version 5.2 Page 23 Members of staff, who spoke to the inspector privately, stated that the current manager (whose application to become the Registered Care Manager is being processed by the central registration team) showed openness in leadership, in her ethos and beliefs, and in the way that she managed the home. One person spoke with appreciation of the flexibility of a person who showed such concern for the welfare of her staff. The person who deals with the documentation relating to finances was not present in the home (as only three hours per week is now allowed by the providers for administrative support to be undertaken on the premises) so was not possible to examine the records relating to personal allowances on this occasion. What was seen however was the recording care plans of various arrangements made for the management of the finances of residents, and that of these lay with either members of their own family, or with some appointed advocates such as a solicitor. The managers and staff of this home were not agents or appointees for any of the residents in their care. Abbots House DS0000028862.V312938.R01.S.doc Version 5.2 Page 24 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 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 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X X X 3 4 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 3 X X 3 Abbots House DS0000028862.V312938.R01.S.doc Version 5.2 Page 25 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. Standard Regulation Requirement Timescale for action 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 Abbots House DS0000028862.V312938.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 Abbots House DS0000028862.V312938.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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