Care Home: Abbotsfield Hall Nursing Home

What has improved since the last inspection? The registered manager now write confirming that, having assessed their needs, the home is able to meet those needs and is suitable for them. This protects both the person to be admitted and the home. Medicines are how kept and administered in line with the Royal Pharmaceutical society guidelines. This reduces the possibility of mistakes or mishandling. Wardrobes have now been secured to the walls and the risk from them falling is removed. There has been an ongoing programme of redecoration within the home. The laundry contains some new equipment, guaranteed to meet current legislation and so ensure the required standard of hygiene. The risk from Legionalla is now reduced/removed by the steps taken at the home to manage the hazard. What the care home could do better: The home continues to start new staff before they have checked if they have a criminal record or have been placed on the list of people unsafe to work with vulnerable adults. This puts people at risk and is the second consecutive time we have found unsafe recruitment. The requirement to employ staff in a safe manner is repeated and enforcement will be considered if this requirement remains unmet. All risks must be assessed so that people who use the service are protected. We have made a repeat requirement that the use of bedsides is risk assessed on an individual basis as this practice may put people at risk of serious injury. Information records should include family and social history so that staff have all relevant information from which to plan and meet people`s needs. This is especially important where people are unable to communicate fully themselves.Abbotsfield Hall Nursing HomeDS0000003572.V375101.R01.S.doc Version 5.2 Page 7 Key inspection report CARE HOMES FOR OLDER PEOPLE Abbotsfield Hall Nursing Home Abbotsfield Tavistock Devon PL19 8EZ Lead Inspector Anita Sutcliffe Key Unannounced Inspection 17:00 22nd. April 2009 DS0000003572.V375101.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Abbotsfield Hall Nursing Home DS0000003572.V375101.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Abbotsfield Hall Nursing Home DS0000003572.V375101.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Abbotsfield Hall Nursing Home Address Abbotsfield Tavistock Devon PL19 8EZ 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) 01822 613973 01822 617260 partners@abbotsfield.fsbusiness.co.uk Mr Eamon Charles Gaffney Mrs Hazel Gaffney, Mrs Pamela Watson, Mr Graham Watson Mrs Pamela Watson Mrs Hazel Gaffney Care Home (with nursing) 28 Category(ies) of Old age, not falling within any other category registration, with number (0) of places Abbotsfield Hall Nursing Home DS0000003572.V375101.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION 2828Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing - Code N to service users of either gender whose primary care needs on admission to the home are within the following category: 2. Old age, not falling within any other category (Code OP) The maximum number of service users who can be accommodated is 28 18th April 2008 Date of last inspection Brief Description of the Service: Abbotsfield Hall is situated on the outskirts of Tavistock. It is owned and managed by Mr and Mrs Gaffney and Mr & Mrs Watson. There is 24 hour trained nurse cover supported by a team of carers and ancillary staff. The home provides nursing and personal care for up to 28 older people of either gender. The home is arranged on 2 floors with a passenger lift and stair lift available. There are 16 single and 6 double bedrooms; a few bedrooms on the first floor do not have level access. The ground floor has two lounges and a dining room. It is well adapted in order to meet the needs of the people who live there. There is a large accessible garden. Information about the home, including a copy of the last inspection report, is available in the entrance hall. The provider told us that the current range of fees is from £301 to £700 a week. Additional charges are made for chiropody, hairdressing, newspapers and toiletries. Abbotsfield Hall Nursing Home DS0000003572.V375101.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this home is 2 star, good. This means that the people who use the service experience good quality outcomes. Information about the home has been collected towards this inspection since April 2008. The providers gave us up to date information about the home prior to the inspection. This included their opinion of the service they provide and some data, such as the number of staff and the needs of people at the home. We also sent surveys to people who use the service and staff. Eight people replied (some completed with their family) and eight staff replied. This key inspection included two unannounced visits, one during the early evening. As part of the visits we looked at all communal areas, the laundry, kitchen and several bedrooms. We spoke with two people who use the service, one family and observed staff going about their work. We looked in detail at the care and support that one person received, meeting them and looking at their care records. We looked at the care records of several others. We spoke with two of the registered owners and two staff. People who use the service may be described as residents, patients or service users within the report. What the service does well: People who use the service told us: “Abbotsfield Hall is a delightful home. Staff and residents are kindly towards each other. Any issues are dealt with straight away and relative are fully informed and always welcomed into the home”. Staff told us: “All general care is very good. Privacy and dignity is always maintained. Equipment is supplied as and when needed”. People are fully informed about the home before they make the decision to move in. Their needs and wishes are fully understood and the home writes to confirm that their assessed needs can be met. People’s admission is thorough and takes into account the challenge this change presents to them. People who use the service receive an excellent level of personal care and the standard of nursing is good. They are also supported to express their individuality and retain their dignity. Staff, some of whom have been at the home for many years, are experienced and demonstrate a high degree of knowledge and skill. Two told us: “It’s a really nice home, friendly, and the staff get on”. Abbotsfield Hall Nursing Home DS0000003572.V375101.R01.S.doc Version 5.2 Page 6 Family and visitors are made very welcome at the home. The term ‘family’ is used frequently to describe the atmosphere of the home and friendliness people say they find there. All areas of the home are extremely clean, including the laundry and kitchen. The home is warm, well maintained, fresh, well equipped and people tell us they like it very much. Bedrooms are personalised and individual to the person. The gardens are attractive and easily accessible. Food is prepared and cooked well and is very tasty. What has improved since the last inspection? What they could do better: The home continues to start new staff before they have checked if they have a criminal record or have been placed on the list of people unsafe to work with vulnerable adults. This puts people at risk and is the second consecutive time we have found unsafe recruitment. The requirement to employ staff in a safe manner is repeated and enforcement will be considered if this requirement remains unmet. All risks must be assessed so that people who use the service are protected. We have made a repeat requirement that the use of bedsides is risk assessed on an individual basis as this practice may put people at risk of serious injury. Information records should include family and social history so that staff have all relevant information from which to plan and meet people’s needs. This is especially important where people are unable to communicate fully themselves. Abbotsfield Hall Nursing Home DS0000003572.V375101.R01.S.doc Version 5.2 Page 7 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Abbotsfield Hall Nursing Home DS0000003572.V375101.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 Abbotsfield Hall Nursing Home DS0000003572.V375101.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 & 5 Abbotsfield Hall does not provide Intermediate Care and so standard 6 does not apply. People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home’s admission process ensures that people are fully informed and their needs fully understood before they are admitted. EVIDENCE: Seven of the eight people who responded to survey told us they had received a contract with the home when admitted. All told us they received enough information about the home. Comments included: “Several visits when the matron and staff were extremely helpful. Literature to further inform the family was available and offered” and “My decision was made by the warm welcome received and the friendliness of the staff”. Abbotsfield Hall Nursing Home DS0000003572.V375101.R01.S.doc Version 5.2 Page 10 We looked closely at the admission of a person recently admitted to the home. He told us he visited Abbotsfield Hall three times and was invited to lunch before he made his final decision about the home. He said: “What swung it was the individual attention from the staff”. He felt that the information about the home was an “underestimation of the actual standards”. He confirmed that the care he was receiving was exactly that which he wanted and needed. We looked at assessment records. We found that all necessary contact details, medical history, assessment of risks such as falls and likelihood of pressure sores and medical observations were recorded. This information informs the home about people’s needs and allows the lead nurse to make a decision about whether or not those needs can be met. We are told that each person receives a contract or statement of terms and conditions and now people receive written confirmation that, having assessed their needs, the home is both suitable for them and can meet those needs. This confirmation protects both the person and the home should problems arise. Abbotsfield Hall Nursing Home DS0000003572.V375101.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 & 9 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People receive a very high level of personal and health care at Abbotsfield Hall Nursing Home. EVIDENCE: Six people told us they always receive the care and support they need and two told us they usually do. Comments included: “Excellent care” and “No complaints here. Care and support is superb”. All who responded to survey told us they always receive the medical support they need. We looked at several care records. The home has adopted a new system for recording care information; staff told us they are still getting used to it. We found that care plans were detailed and informative and a reflection of the person’s needs. They are reviewed and updated as necessary and take into Abbotsfield Hall Nursing Home DS0000003572.V375101.R01.S.doc Version 5.2 Page 12 account sudden changes in needs, such as a chest infection. Staff should therefore always have the written information they need available to them. Staff confirmed that there is also a verbal hand over of information between them. Four told us this is always enough and two said it usually is. We found the standard of personal care delivered was extremely high and people were helped to be individual in the way they present – staff go the ‘extra mile’. Records show that outside health care professionals, such as optician and podiatrist, are contacted as necessary. Health is therefore promoted. One person told us: “When my mother’s hearing aid has gone missing staff have always taken time to find it”. Another said: “Needs are always assessed and managed promptly and professionally”. We found that medicines are now being managed more safely. Storage, delivery and records met the required guidelines and regulations. People are treated with dignity and respect at Abbotsfield Hall. We were told this and observed it repeatedly throughout the two visits. Where people share rooms there are screens available and each person is able to lock their door for privacy should they wish. Abbotsfield Hall Nursing Home DS0000003572.V375101.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service receive a peaceful, pleasant life and a good standard of food. EVIDENCE: We saw people sitting in the lounges, some reading. People do not stay in their room unless very unwell or they wish to. Asked through survey if there are activities arranged at the home that they could take part in, one person said always, two said usually, three said sometimes and one said never. Comments included: “More activities needed” and “I am quite private but there are some activities I enjoy”. There are two pianists who visit the home regularly and we are told this is much enjoyed. We saw people with the hairdresser and are told there is a monthly Communion. Library books are available regularly replaced. Some people are able to access the local community, but some are very frail and do Abbotsfield Hall Nursing Home DS0000003572.V375101.R01.S.doc Version 5.2 Page 14 not leave the home. The providers tell us their service would be improved if they arranged outings in and around the Tavistock area. The gardens at Abbotsfield Hall are very attractive and easily accessible regardless of poor mobility. We were told of occasional ‘tea on the lawn’. The plans of care we saw contained some information about family and social history but this remains quite limited. Visitors to the home tell us they feel very welcome and the visiting arrangements are very flexible. The term ‘family’ is used frequently to describe the atmosphere of the home and friendliness people say they find there. Six people told us they always enjoy the meals at the home and two people said they usually do. Staff feel the menu is a little too repetitive and the provider agreed they should offer some more imaginative options. However, comments about the meals included: “All home meals and fresh vegetables – what more could you ask – you should try cook’s homemade pasties”. We tried the homemade profiteroles and they were very tasty. Special diets are available when health needs require this. There is not a regular vegetarian option. Staff assist people with their food as necessary, taking their time to do so. Diet is well monitored at the home with records of people’s weight and any changes of concern noted and followed up. Abbotsfield Hall Nursing Home DS0000003572.V375101.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People at the home are protected by the accessibility of the staff and providers and the home’s policies and procedures. EVIDENCE: There is a complaints procedure displayed in the entrance hall and within the guide about services. It was clear from observation that people who use the service and their family/visitors felt comfortable discussing issues with the staff and managers. The record of concerns and complaints showed that there had been no entries since 2003. When this was discussed we were told that any issues raised were dealt with promptly and did not lead to a complaint. Each of the six people who responded to survey said they know who to speak to if they are not happy and how to make a complaint, one adding: “Never had occasion to do so”. The Commission has not received any complaints about the home. The home’s policy and procedures for safeguarding adults from abuse is readily available to staff. Staff told us they have received training in the safeguarding of vulnerable adults and were able to describe the types of abuse and what steps they should take if they had concerns. Abbotsfield Hall Nursing Home DS0000003572.V375101.R01.S.doc Version 5.2 Page 16 Abbotsfield Hall Nursing Home DS0000003572.V375101.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22, 23, 24, 25 & 26 People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People benefit from a home that is extremely clean, fresh, well maintained, full of character and contained all necessary equipment to meet people’s needs. EVIDENCE: We visited all shared areas of the home, the kitchen, laundry and some bedrooms. For both visits the home was fresh and cleanliness was of a very high standard. This included areas unseen by visitors: the laundry and kitchen. Bedrooms were very personalised and homely and each person had a key to the room just inside the door so that it could be locked when leaving if they wished. Abbotsfield Hall Nursing Home DS0000003572.V375101.R01.S.doc Version 5.2 Page 18 Staff told us they had all the necessary equipment needed, for example to help immobile people with movement and prevent pressure sores, and equipment did appear to be well provided. We saw that areas had been redecorated within the last year and new soft furnishings had been fitted in the sitting/TV room. All was fresh and in a good state of repair. The provider/owners tell us they have plans to redecorate the dining room, main hall/function room and fit new carpet, replace some bedroom furniture and continue exterior painting and repair. There is a large garden accessible to people with mobility problems. Each room had hand-washing facilities for staff, to reduce the likelihood of cross infection. Staff have protective clothing available to them for the same reason and they told us they receive training and updates about how to prevent and control infection. The laundry contains some new equipment, guaranteed to meet current legislation, which would ensure that it meets the needs of a nursing home. There is a sluice facility for the cleansing of toiletry aids, such as commode pans. All who responded to survey told us the home is always fresh and clean, one added: “Yes, it’s spotless – even under the beds!” Abbotsfield Hall Nursing Home DS0000003572.V375101.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Recruitment remains unsafe but staff are skilled and competent in the work they do. EVIDENCE: The home maintains a core of staff that have worked there for many years providing consistency and experience. Eight staff responded to survey and we asked two care staff questions when we visited. Asked if staff are available when needed five people told us they always are and two said they usually are. One told us: “Whatever grade, the staff are always available, courteous and responsive to the needs of residents and their families. Kitchen staff are exceptionally kind also”. Another said: “Staff work very, very hard and generally answer (call bell) as soon as possible”. Five staff told us there are always enough staff to meet the individual needs of people, two said there usually are and one said sometimes, adding: “There is a greater number of staff required for evening shifts – often there are too few staff to give the service users the time and attention they need (and deserve)”. Abbotsfield Hall Nursing Home DS0000003572.V375101.R01.S.doc Version 5.2 Page 20 Staff told us during the visits that they felt staffing numbers could be improved. However, people’s needs appear to be well met. The home employs a full compliment of ancillary staff to support the care workers and nurses. Asked if their induction training covered everything they needed to know to do the job when they started five said very well and two said mostly. Staff interviewed said their induction was good. Most staff, who completed surveys, told us they are given training which is relevant to their role, helps them understand and meet the individual needs of people at the home and keeps them up to date. However, one added: “Could do with much more teaching and informal training”. Staff we spoke with told us they thought the training provided was very good and that people are encouraged to take qualifications to improve their knowledge. They listed the regular health and safety training they receive and said some staff are taking additional training in dementia care and nutrition. People who use the service and their family feel that staff are very competent and skilled. We looked at the recruitment records of the last three staff to be employed at the home. Staff must be employed that are safe to work with vulnerable adults. To this end checks must be completed before staff start working at the home. The POVA scheme, run by the Department of Health, is an important part of this. People should be referred to, and included on, the POVA list if they have abused or harmed vulnerable adults in their care or placed them at risk of harm. It is also expected that two written references, a full employment history and a check of the person’s criminal history is completed before they being employment. For a second year we found that the providers/employers at Abbotsfield were not thorough in their recruitment practices. In only one of the three cases were each of the checks complete. Abbotsfield Hall Nursing Home DS0000003572.V375101.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Many aspects of the service are very good/excellent but lack of attention to safety remains an issue to be dealt with. EVIDENCE: The home is owned and run by two married couples. The wives are both registered nurses and share the responsibilities of the position of Registered Managers between them. Both have obtained the Registered Manager’s Award, an indicator of their competence. Abbotsfield Hall Nursing Home DS0000003572.V375101.R01.S.doc Version 5.2 Page 22 We saw that there was relaxed communication between the manger on duty and the people who use the service, staff and people who visited. Staff told us how supportive and accessible the management are and visitors tell us they are very friendly. We looked at how the home makes judgements about the quality of the service that is provided. Surveys are sent to people who use the service, their family, staff and external health care professionals, such as G.P. The provider/owners tell us that from listening to people that have redecorated the large TV lounge and increased the musical entertainment available. Also, that they will change the menu ‘slightly’ with people’s likes and dislikes in mind. Staff told us they have meetings and appraisal of their work, though not regular formal supervision, which is recommended as good practice. However, they told us that their daily work is well supervised and any issue can be taken to management to discuss. The home keeps an allowance for some people who use the service. This is kept securely with records double signed and a clear balance of money remaining. We checked two and found the balance matched the record. We are told few people can manage their own financial affairs and that family do this for most people at the home. We found no health and safety concerns with the exception of no assessment of risk associated with the use of bedsides. We are repeating the requirement that this risk is fully assessed with records of the assessment, as entrapment can be fatal. There are two repeat requirements following this inspection, both associated with the protection of people who use the service. This lets an otherwise very good service down. Abbotsfield Hall Nursing Home DS0000003572.V375101.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 3 3 4 4 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 4 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 3 17 X 18 3 3 X X 3 3 3 3 4 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 2 Abbotsfield Hall Nursing Home DS0000003572.V375101.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 OP29 Regulation 19 Requirement Timescale for action 30/04/09 2. OP38 13 (4) The registered person must not employ a person to work at the care home unless all the required checks - paragraphs 1 to 9 of Schedule 2 of the care home regulations - have been completed so the home can be sure the person does not have a criminal record and is safe to work with vulnerable adults. This was been a previous requirement at the home and not met by timescale of 18th April 2008. All potential risk to people who 16/05/09 use the service must be assessed, including the use of bedsides. Not met by timescale of 16th May 2008. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Abbotsfield Hall Nursing Home DS0000003572.V375101.R01.S.doc Version 5.2 Page 25 No. 1. Refer to Standard OP12 Good Practice Recommendations To ensure the lifestyle in the home matches the expectations of those people living in the home people should have their social, cultural and recreational interests recorded including a plan on how to meet them. This good practice recommendation has been repeated. Abbotsfield Hall Nursing Home DS0000003572.V375101.R01.S.doc Version 5.2 Page 26 Care Quality Commission South West Region Citygate Gallowgate Newcastle upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.southwest@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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