Care Home: Abbeyfield Lodge

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What the care home does well The home has a comprehensive assessment process in place in looking at the needs of both potential and existing service users to ensure that the home can meet their needs. The service users are provided with a warm, homely accommodation that they said met their needs. The care plans and records of care given ensured that residents received the support and help they required. The management system and procedures in the home worked well including, dealing with complaints, staff supervision and the service users` money. The service has staff that are skilled and knowledgeable about the care needs of the people living at the service and seek support from other professionals. What has improved since the last inspection? The care plans and records of care given were detailed and there were regular reviews of the care provision. The service has a registered manager who has day-to-day management responsibilities for the service. The activity room has been moved so that this is now easily accessible as it is in the main building. The people have a shower room on the ground floor that gives them an extra bathing facility. What the care home could do better: The record of all complaints and any action taken following a complaint investigation should be available at the service. Record of mandatory training for temporary/ bank staff must be available to ensure the safety of people using the service. Infection control procedures must be in place to include disposable towels in communal areas and no communal toiletries for people living at the service. The manager must ensure that only registered nurses are responsible for the people`s using the service medication. CARE HOME ADULTS 18-65 Abbeyfield Lodge 184-186 Reading Road South Church Crookham Fleet Hampshire GU52 6AE Lead Inspector Anita Tengnah Unannounced Inspection 16 October 2007 10:00 th Abbeyfield Lodge DS0000065818.V347195.R01.S.doc Version 5.2 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 Abbeyfield Lodge DS0000065818.V347195.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 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. Abbeyfield Lodge DS0000065818.V347195.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbeyfield Lodge Address 184-186 Reading Road South Church Crookham Fleet Hampshire GU52 6AE 01189 581950 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) Truecare Holdings Limited Sandra Johnson Care Home 12 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (12) of places Abbeyfield Lodge DS0000065818.V347195.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing (N) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Mental disorder, excluding learning disability or dementia (MD) The maximum number of service users to be accommodated is 12. Date of last inspection 12th October 2006 Brief Description of the Service: Abbeyfield Lodge is a care home registered to provide personal and nursing care to adults with a mental disorder. There is no provision for the detention of people under the Mental Health Act 1983, although residents may be under community supervision arrangements of the Act. A Registered Mental Nurse (RMN) is on duty at all times. The home works jointly with local hospital and community psychiatric services. Placements at the home may be part of a rehabilitation programme following discharge from an acute psychiatric ward. The home is involved in multi agency planning meetings for individual residents. The facilities of the home ensure that this meets with the people’s needs. There is a computer with access to the internet and e-mail for the residents to use. The current fee charged is £1200- £1600 per week. Abbeyfield Lodge DS0000065818.V347195.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced visit to the service was undertaken as part of the inspection on the 16th of October2007. The process included a tour of the service where a number of the bedrooms, communal areas, kitchen, and bathrooms were viewed. As part of case tracking 3 staff and 2 service users views were sought and care records were looked at. Questionnaires were also sent to the people using the service in order to seek their views. Information gained from the Annual Quality Assurance Assessment (AQAA) was also used and included in this report, as was information gathered by the commission since the last inspection to contribute in assessing judgements in this report. Positive comments were received from the service users regarding the care that they were receiving at the home. The commission received 6 comment cards from the service users and these indicated that people were happy with the care that they are receiving. Care practices observed at the time of the visit showed that the staff and the service users had developed good relationships and care was provided in a respectful manner. What the service does well: The home has a comprehensive assessment process in place in looking at the needs of both potential and existing service users to ensure that the home can meet their needs. The service users are provided with a warm, homely accommodation that they said met their needs. The care plans and records of care given ensured that residents received the support and help they required. The management system and procedures in the home worked well including, dealing with complaints, staff supervision and the service users’ money. The service has staff that are skilled and knowledgeable about the care needs of the people living at the service and seek support from other professionals. Abbeyfield Lodge DS0000065818.V347195.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. Abbeyfield Lodge DS0000065818.V347195.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Abbeyfield Lodge DS0000065818.V347195.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 2 The pre admission assessment process is good and ensures that service users’ needs are assessed and the home can meet them. EVIDENCE: The care records of two recently admitted service users were looked at as part of case tracking. Detailed pre admission assessments of needs were carried out and staff reported that this information is used to formulate their care plans on admission. Assessments of needs included medication, personal risk taking, maintaining independence, personal hygiene and social inclusion. Care manager’s assessment was also sought at the time of referral. The manager or a senior staff member also attended multi disciplinary meetings as part of the initial referral. Comment card received indicated that information was available and one of the comments was “ my parents thought this was the best place for me”. One of the care record showed that as part of the assessment process one of the people stayed for a week to “test out the service” prior to moving in. The manager reported that this works well for both the new person and others already at the service. Abbeyfield Lodge DS0000065818.V347195.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 6,7,9 The care plans were detailed and there was evidence of the people’s involvement in care planning. However this must include how the social and educational needs of people will be met and needs further development. Service users are supported to live independently within a risk assessment framework. EVIDENCE: The care records of three people were looked at as part of this visit. The care plans were detailed and included risk assessments. Each of the record seen indicated that the individualised care plans were in place that showed how their assessed needs would be met. There was evidence that people using the service were involved in the formulation of their care plans. Risk assessments included personal safety, harassment, sexual vulnerability as well as personal Abbeyfield Lodge DS0000065818.V347195.R01.S.doc Version 5.2 Page 10 care and diabetes monitoring. Care plans were in place to demonstrate how these identified risks would be managed. Care plans also indicated that the people using the service were assisted in promoting their independence. The care plans included taking responsibility for certain activity of daily living such as making their beds and tidying their bedrooms. One of the care plans seen for a newly admitted service user was not formulated until three weeks following admission. The manager is aware that care planning must be started as soon as people move into the service in order to ensure that all staff have the right information on how that person needs would be met. The two people spoken with stated that they have the support they needed and that the staff were “very good and you can talk to them”. The care plans did not indicate how the people’s recreational and educational needs would be addressed. The recreational and educational needs of people using the service must be further developed. The manager reported that the educational needs of the people had not been fully met and this was due to recent staff shortages. This was related to a person who wanted to start college in September and had not been able to do so. The manager said that was being addressed with the employment of a social carer and another member of staff. The person was applying and hoping to start college in January 08 and the manager stated that staff would be available to offer support This must be further developed and support available included to foster their independence and personal goals reflected. The people are supported in taking risks as part of independent living and these included length of time they are allowed to be away from the service before staff have to take action. Reviews included psychological report and the manager discussed that each of the people using the service had an assigned key worker who held regular one-to-one support as required. Abbeyfield Lodge DS0000065818.V347195.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 12,13,15,16,17 There is a range of activities available to meet their needs and people are encouraged to be part of the local community. The care practices ensured that people’s privacy and rights are respected. Meals were good and met with the people’s satisfaction. EVIDENCE: It was evident from discussion with the people using the service and the comments cards received that the home has a variety of activities available to them. These included art and craft classes that are held at the service and three others attended the social club on alternate Wednesday in the community. Residents spoken with said that they are supported to maintain Abbeyfield Lodge DS0000065818.V347195.R01.S.doc Version 5.2 Page 12 links with their family and friends. One of them was going out shopping on the day of the visit. A comment received was” I usually go swimming once a week and to the club every fortnight”. Other comment was that “we could have trips at the weekend if there are staff”. The residents spoken with said that they were treated with respect and their rights respected. Staff were observed to knock prior to entering the people’s bedrooms. Comments received and interaction observed throughout the day indicated that the staff and the people living at the home had developed good relationships. The home has a snack menu for the lunchtime meal and the main meal is taken in the evening. The people spoken with said that this was “all right” and they preferred their meals later in the day. Comments received indicated that the meals were good. Hot and cold drinks were available at all times and the people were observed to help themselves to hot drinks and offered them to the staff. Evening meals had two choices and people said that they “could have anything they choose”. Abbeyfield Lodge DS0000065818.V347195.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 18,19,20 Support is provided to meet the needs of people living at the service. Medication records were satisfactory. Procedures to ensure that only registered nurses have sole responsibility for medication management must be put in place. EVIDENCE: Care records seen indicated that the people are independent in their personal care, however where prompts are needed these are recorded in the care plans. Staff reported that none of the people required assistance with personal care and two people spoken with said that their autonomy and choices were respected. There were no restrictions in the activity of daily living. Comments included “I get up to take my morning medication and then I can go back to bed”. Staff reported that there were some agreements with medication and these were reflected in care planning. All the people living at the service are registered with a doctor in the local community. The manager reported that the Community Psychiatric Nurse Abbeyfield Lodge DS0000065818.V347195.R01.S.doc Version 5.2 Page 14 offered the home and the people living there support and advice as required. The manager reported that there is a Registered Mental Nurse available at the home that provided twenty- four- hour cover. The home has a medication policy and procedure in place for the management of people medication. The manager reported that no one was administering his or her medication at the time of the visit. Risk assessments and consents were available in care records seen relating to medication. All the medicines were stored safely including those that should be kept as controlled drug. A sample of the Medication Administration Record (MAR) seen indicated that appropriate records were maintained on administration of medication. The manager was made aware that only Registered nurses must deal with the people’s medication. A review is needed and clear procedures must be adopted in order to meet with the regulation, guidelines from the Royal Pharmaceutical Society and the medicines act. The manager confirmed at the time of the visit that this would be put in place with immediate effect. Abbeyfield Lodge DS0000065818.V347195.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. 22,23 People using the service are confident to raise any concerns with the home. Procedures are in place and training for staff are available to ensure the people are protected from abuse. EVIDENCE: The home has a complaint procedure that was displayed in the entrance hall and readily available to people using the service. Comments received and two of the people spoken with confirmed that they would be comfortable to raise their concerns with the manager or other staff members. Comments included “the staff are good and they do listen”. Another comment was “things are all right”. The home has a complaint log. The commission received a complaint that was referred to the hope to investigate. The manager reported that this was looked into at head office, however there was no record of this at the service. The manager confirmed that she would be contacting head office and a copy of the investigation and outcome would be maintained in the complaint log as required. The commission has a copy of the investigation on file. The home has in place the Hampshire Adult Protection procedure and the service own procedure was displayed in the office as a chart to inform practice. Staff spoken with reported that they would report to the manager any Abbeyfield Lodge DS0000065818.V347195.R01.S.doc Version 5.2 Page 16 allegation of abuse. Staff who are left in charge of the home should ensure that they are familiar with the procedure for reporting and recording all allegation of abuse in the absence of the manager. Training in adult protection was available for staff and the manager reported that further updates were planned. At the time of the visit the home was managing some of the people’s personal allowances. A record of all transactions was maintained and by a staff member and the service user concerned signed for any deposit and withdrawal. Money was maintained individually and securely. A random check indicated that the balance recorded was correct. Staff confirmed that these were the only monies that the home supported the people with. Information/access on advocacy service for people living at the home was discussed and the manager said she would be looking into this. Abbeyfield Lodge DS0000065818.V347195.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 24,30 The people were provided with a clean and homely environment that met their needs. The laundry room was well managed. The use of communal toiletries and lack of disposable towels in the communal areas pose infection control risks. EVIDENCE: A number of bedrooms, communal lounges, bathrooms, kitchen and laundry were looked at as part of this visit. The people using the service are provided with a homely and clean environment to live in. Furnishing was of good standard and appropriate to the needs of the people living there. Recent update included a walk in shower room on the ground floor. There are appropriate communal spaces for people to use and included an activity room with a computer and Internet access. This room has been renovated and forms Abbeyfield Lodge DS0000065818.V347195.R01.S.doc Version 5.2 Page 18 part of the house and afforded easier access for the residents. The home as a small garden with seating available and a further room used as a smoking room. The bedrooms seen were personalised and staff reported that people are encouraged to bring in items of personal belongings and personalise their rooms. Some parts of the home were in need of renovation such as worn carpets and tired décor. The manager reported that this has been identified as part of the business plan and would form part of the refurbishment of the service. There are two communal bathrooms and a shower facility on the ground floor. It was noted that there were a number of communal toiletries including bars of soaps in all the communal washing rooms. This was discussed as they pose an infection control risk and did not promote individualised care. The manager confirmed that this would be addressed immediately. The home has a laundry and all the people’s washing was undertaken internally. The laundry room was clean and in good state of repair. Infection control procedures were in place to ensure that the people are protected. The communal areas had liquid soaps and did not have disposable towels. This was brought to the attention of the manager as this poses an infection control risk and must be addressed. Abbeyfield Lodge DS0000065818.V347195.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Competent and qualified staff supports Service users. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 32,34,35,36 There are adequate staff with appropriate skills to meet the present needs of people living at the service. There is a robust recruitment process in place that ensures that people using the service are safeguarded. EVIDENCE: The manager confirmed that there are three staff on the day shifts and two waking night staffs. There were registered nurses on duty that provided twenty-four hour cover at the service. The registered manager was supernumerary and was employed full time to support the staff. Comments received and people spoken with say that there were adequate staff to meet their needs. Other comment was that “it would be good to have staff to go on trips at the weekend”. Abbeyfield Lodge DS0000065818.V347195.R01.S.doc Version 5.2 Page 20 The manager reported that staff recruitment included having three staff on day duty and an activity coordinator was due to start soon. This would enable the staff to support people in attending college in the evenings, as this had been an area of recent shortfall. Other supports included an art therapist that attended the home for five hours a week. A sample of staff record was looked at and this included two newly recruited staff. This indicated that there is a robust recruitment procedure in place that staff followed. Both new staff had completed application forms and references were sought including one from their last employer. The appropriate checks were carried out on staff including the completion of Criminal Record Bureau (CRB) and Protection of Vulnerable Adults (POVA) applications. Staff started work on receipt of full clearance. The home has a training programme in place. The home has core staff members who have worked at the service long term and have the skills and experience to care for the client group accommodated. Comments from people using the service and interaction observed indicated that the staff and people they are supporting had developed good relationships with each other. The residents were attended to in a respectful manner. Mandatory training records in health and safety including fire safety were available for permanent staff, however the records of mandatory training for bank staff were not up to date. New staff completed an in house induction. The service did not have an induction as Skills for Care and the manager reported that she would be accessing this for all newly recruited staff. Information from the AQAA indicated that of the eight permanent staff three had completed National Vocational Qualification (NVQ) 2 and above. However none of the bank staff had achieved this qualification. Further development in NVQ training is needed to ensure that carers achieve this training. A requirement was raised at the last visit about the lack of structured supervision for staff. Staff spoken with and supervision plan seen indicated that there is monthly supervision programme in place for all staff. This requirement has been met. Abbeyfield Lodge DS0000065818.V347195.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 37,39,42 The management at the home has good support for the people using the service. The health and safety of people using the service are promoted. EVIDENCE: Since the last visit the home has recruited a manager and she has been registered with the commission. Information received and staff spoken with indicated that there is a stable management team in place providing support for staff. There are clear lines of accountability within the home. The manager has a deputy who is a Registered Mental Nurse (RMN) to support her in her role. The operational manager undertakes regular visits to the home and completes report as Regulation 26. Staff reported that an audit of the service users’ Abbeyfield Lodge DS0000065818.V347195.R01.S.doc Version 5.2 Page 22 relatives and healthcare professionals was undertaken in February 07 as part of the monitoring of the service delivery. The manager confirmed that she had this month completed her business plan and included refurbishment/ upgrade plan for the service. Information received indicated that there is an ongoing programme for the servicing of equipment and emergency lighting. Regular reviews of policies and procedures are in place to meet with current regulations and good practice guidance. The last review was completed in February 07. All substances that are hazardous to health were maintained safely. Risk assessments were in place for some of the service users who use cleaning chemicals. Abbeyfield Lodge DS0000065818.V347195.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 Adults 18-65 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 2 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 3 X Abbeyfield Lodge DS0000065818.V347195.R01.S.doc Version 5.2 Page 24 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 14 and 15 Timescale for action The educational and occupational 30/11/07 needs must be assessed and recorded. Care plans must be devised to demonstrate how these needs would be met. The registered person must 30/10/07 ensure that only Registered Nurses must administer medicine to people using the service and including controlled drugs. A record of all complaints made 30/11/07 including details of investigation and action taken must be maintained at the service. As part of infection control 30/11/07 procedures, hand-washing facilities such as disposable towels must be available in all communal areas. Requirement 2 YA20 13(2) 3 YA22 17(2) Schedule 4 (11) 13(3) 4 YA30 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations DS0000065818.V347195.R01.S.doc Version 5.2 Page 25 Abbeyfield Lodge Standard Abbeyfield Lodge DS0000065818.V347195.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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. 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