Care Home: The Abbeys

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What the care home does well People who may wish to use the service have the necessary information they need to make an informed decision about The Abbeys. People using the service and the relatives are given the opportunity to visit the home and spend time at the home before admission. The health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice bythe staff who work at the home so that the people are able to live happily and comfortably. Most people who use services are able to make choices about their lifestyle. The staff support the people using the service, so that they are able to maintain their life skills. The people using the service are able to express their concerns and have access to a complaints procedure. The people using the service and the staff working at the home are protected from abuse by the home`s policies and staff awareness and training. The physical design and layout of the home enables people who use the service to live in a safe, well-maintained and comfortable environment, which encourages independence. The staff working at the home are trained and skilled to support the people who use the service. The management of the home is based on respect and good communication with people using the service and the visitors. The quality assurance systems in place are effective and help to improve the service. What has improved since the last inspection? The following requirements and recommendation from the last key unannounced inspection had been actioned. We checked the progress during this inspection site visit. The information documented in care plans was as far as practicable accurate and reflected the person`s needs. Therefore resulting in appropriate interventions by the staff. The people were offered medication in the form suitable for him/her, when people refused to take prescribed medication in a certain form (e.g. tablets) Most of the staff working at the care home had received training on palliative care or end-of life care. This has given the staff confidence and an insight into practical assistance to relatives & advice on death & dying to the person and their representatives. We noticed that the people using wheelchairs were offered a dining chair when having their meals at the dinner table. Thereby giving the people the choice and promoting mobility. The number and types of hoists available at the home were appropriate to the dependency levels and the needs of the people occupying the home. The staff supervision has been carried out regularly, so that all aspects of their practices were monitored and the management were able to identify staff career development needs. The manager was able to provide evidence of supervision records. The supervisions enable staff to have a two-way feedback with their line managers and assess their progress and empower themselves. The people living at the home, relatives and other visitors have been made aware of the choice of activities available at the home. They knew that they should ask the care staff or look at the notice board for the information. The people at the home, the staff and the relatives have been informed of the availability of food supplement `Smoothies`. Whenever possible natural produce is used to maintain a lifestyle in line with healthy eating. The meals looked appetising when served to people. The residents and/or their representatives have been offered copies of their Terms & Conditions of stay by Southern Cross. These are reviewed each year when fee reviews take place. The people living at the home and their representatives have been made aware of their right to be involved in the planning of care. The outcome focused care plan will enhance people involvement. What the care home could do better: The staff should be given formal time for the handover between shifts and the management should not expect the staff to come earlier in their own time in order to take handover so that they are able to maintain continuity of care. The management must ensure that the staffing numbers on each unit reflect the dependency levels of the people using the service. The key workers should be given time to attend to the personal, social and recreational needs of the people whom they are responsible for. CARE HOMES FOR OLDER PEOPLE The Abbeys High Street Rawmarsh Rotherham South Yorkshire S62 6LT Lead Inspector Marina Warwicker Key Unannounced Inspection 9th September 2008 09:50 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 The Abbeys DS0000003069.V363819.R02.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. The Abbeys DS0000003069.V363819.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Abbeys Address High Street Rawmarsh Rotherham South Yorkshire S62 6LT 01709 719717 01709 710149 theabbeys@schealthcare.co.uk 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) Southern Cross Operations Limited Alison Tripp Care Home 80 Category(ies) of Dementia (80), Old age, not falling within any registration, with number other category (80) of places The Abbeys DS0000003069.V363819.R02.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 - Code N, to service users of the following gender: Either, whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP and Dementia - Code DE The maximum number of service users who can be accommodated is: 80 1st May 2007 2. Date of last inspection Brief Description of the Service: The Abbeys are situated just off a main road in Rawmarsh, Rotherham with public transport to the town centre. It comprises of two separate buildings Abbey Hill and Abbey Dale. Abbey Hill is a two- storey building with 55 bedrooms. It is divided into three units. The Fern, the Wedgwood and the Rosecote. The Fern has 18 beds and provide personal care for older people with dementia. The Wedgwood has 18 bedrooms and provides mainly nursing care for older people. The Rosecote, which is on the ground floor, has 19 bedrooms. The majority of people living on this floor require personal care. Abbey Dale is a three -storey building for older people requiring help with personal care only. Passenger lifts give access between the floors and there are level entrances and ramps to the buildings including those giving access to the gardens. In total up to 80 people can be accommodated at The Abbeys. All rooms are single occupancy and some have en-suite facilities. The weekly fees ranged from £358 to £473, at the time of this visit. Information with regards to the service was available in the form of the service user guide and the statement of purpose at the entrance hall of the home. The Abbeys DS0000003069.V363819.R02.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 service is 2 star. This means that the people who use this service experience good quality outcomes. An inspection of this care home was carried out on Tuesday 9th September 2008, between 9.50 am and 3.40 pm. The staff, the manager and the people using the service were not informed of our visit and therefore it was unexpected. Twelve people who use the service and five visitors were consulted on the day. We also spoke with seven staff who were on duty and two visiting professionals. Any comments received after the publication of this report will be shared with the management of the home. We spoke to people using the service, relatives and the staff to get an insight into the quality of life and the standard of care and dignity given to the people, as well as looking at the quality of food and activities where people were involved. The premise was inspected, which included bedrooms of people using the service, the communal areas and the service areas such as the kitchen and the laundry. The private areas were accessed with the permission of the people and the staff at the home so that we respected the people’s wishes. Samples of records such as the care plans, staff recruitment and training files were checked. We would like to thank the people who live at the Abbeys, their relatives, the staff and the management for their contribution towards this process. What the service does well: People who may wish to use the service have the necessary information they need to make an informed decision about The Abbeys. People using the service and the relatives are given the opportunity to visit the home and spend time at the home before admission. The health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice by The Abbeys DS0000003069.V363819.R02.S.doc Version 5.2 Page 6 the staff who work at the home so that the people are able to live happily and comfortably. Most people who use services are able to make choices about their lifestyle. The staff support the people using the service, so that they are able to maintain their life skills. The people using the service are able to express their concerns and have access to a complaints procedure. The people using the service and the staff working at the home are protected from abuse by the home’s policies and staff awareness and training. The physical design and layout of the home enables people who use the service to live in a safe, well-maintained and comfortable environment, which encourages independence. The staff working at the home are trained and skilled to support the people who use the service. The management of the home is based on respect and good communication with people using the service and the visitors. The quality assurance systems in place are effective and help to improve the service. What has improved since the last inspection? The following requirements and recommendation from the last key unannounced inspection had been actioned. We checked the progress during this inspection site visit. The information documented in care plans was as far as practicable accurate and reflected the person’s needs. Therefore resulting in appropriate interventions by the staff. The people were offered medication in the form suitable for him/her, when people refused to take prescribed medication in a certain form (e.g. tablets) Most of the staff working at the care home had received training on palliative care or end-of life care. This has given the staff confidence and an insight into practical assistance to relatives & advice on death & dying to the person and their representatives. We noticed that the people using wheelchairs were offered a dining chair when having their meals at the dinner table. Thereby giving the people the choice and promoting mobility. The number and types of hoists available at the home were appropriate to the dependency levels and the needs of the people occupying the home. The Abbeys DS0000003069.V363819.R02.S.doc Version 5.2 Page 7 The staff supervision has been carried out regularly, so that all aspects of their practices were monitored and the management were able to identify staff career development needs. The manager was able to provide evidence of supervision records. The supervisions enable staff to have a two-way feedback with their line managers and assess their progress and empower themselves. The people living at the home, relatives and other visitors have been made aware of the choice of activities available at the home. They knew that they should ask the care staff or look at the notice board for the information. The people at the home, the staff and the relatives have been informed of the availability of food supplement ‘Smoothies’. Whenever possible natural produce is used to maintain a lifestyle in line with healthy eating. The meals looked appetising when served to people. The residents and/or their representatives have been offered copies of their Terms & Conditions of stay by Southern Cross. These are reviewed each year when fee reviews take place. The people living at the home and their representatives have been made aware of their right to be involved in the planning of care. The outcome focused care plan will enhance people involvement. 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. The Abbeys DS0000003069.V363819.R02.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 The Abbeys DS0000003069.V363819.R02.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3&5 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. People who may wish to use the service have the necessary information they need to make an informed decision about The Abbeys. EVIDENCE: Four care plans were checked, three staff were consulted and other relevant records were also checked. The service user guide was informative and had the relevant information so that the people were able to find out about the service delivered at the home. The people using the service said that their families were given information by the staff at the home when they came to see ‘the place’. The Abbeys DS0000003069.V363819.R02.S.doc Version 5.2 Page 10 The care plans had copies of the needs assessments by the placing authorities and also the home management assessments, which had taken place prior to admission. The people using the service had been offered the Terms and Conditions by the administration at the home. Most people had signed the agreements and copies were held by the administrator. People using the service, the relatives and two staff confirmed the there were opportunities to visit the home and spend time at the home before admission. However when people came straight from the hospitals they were unable to have trial visits. But a relative told us that all the people using the service were able to change their minds and leave whenever they so wish. During our conversation people knew their rights and were happy to be at the home. The Abbeys DS0000003069.V363819.R02.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&11 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. The health and personal care that people receive is based on their individuals’ needs. The principles of respect, dignity and privacy are put into practice by the staff who work at the home so that the people are able to live happily and comfortably. EVIDENCE: Four care plans were checked and four staff were spoken to. We checked the documentation and observed the delivery of care during our visit. We were informed that the home is focusing on the delivery of a ‘Person Centred Care’ and that the documentation was being changed to achieve this. We were shown some of the work carried out by the nurses. The information seen was relevant; outcome focused and ensured that the care plans were unique to each individual. We also observed the care staff documenting in the care plans. This practice can only be commended, as the key workers/carers, they are the frontline staff The Abbeys DS0000003069.V363819.R02.S.doc Version 5.2 Page 12 and they need to be able to document what care was delivered and what type of a day their ‘residents’ have had. There was evidence of regular reviews of care plans and three relatives said that they were included in the reviews by the staff or informed them of any changes when the staff next saw them. The staff said that they had equipment to promote pressure care. We also witnessed staff organising trips for the people using the service to attend health professional appointments. The staff had assessed the people using the service and according to their capacity the people’s medication was managed. There had been regular audits by the supplying pharmacists to ensure the home was complying with the Medication Act 1968 and Misuse of Drugs 1971. The nurses handled medication on the Nursing units and the senior carers who had completed medication training engaged in the administration of medicine in the Personal Care units. We observed staff during the day. We spoke with the people using the service and some of the staff to find out how the privacy and dignity of the people was maintained at the home. These were some of the comments. “Handover between shift are carried out in a private place so that visitors or the residents don’t overhear what was said about other residents.” “The staff always shut the bedroom door before attending to peoples’ personal care. I have heard them explaining and keep talking to them when they attend to the people.” “ One of us, is here most days and we see and hear what goes on at the home. The majority of staff are very friendly, jolly and know what people are like or need. We can’t expect more than that.” “I treat these older people like my own. They want to be cared for and just like a bit of love and attention. We can’t please everybody but I try to be understanding and do my best.” The manager said that the staff were given training by the local hospice staff on palliative care and that this was ongoing. Two staff interviewed said that although they had not yet received the training they were confident that they will be attending training soon. The Abbeys DS0000003069.V363819.R02.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&15 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. Most people who use services are able to make choices about their life style. The staff support the people using the service, so that they are able to maintain their life skills. The management could provide more support to the people living at the home so that they are able to explore and enjoy the social, cultural and recreational aspects of their daily lives. EVIDENCE: On the day of our site visit the activities organiser was on leave. This left the people using the service without any formal entertainment or activities. There were charts displayed in the units informing people what types of activities had been arranged. The staffing levels on the day did not accommodate providing activities to people using the service. However each unit had different strategies to cope with this. On one of the units, a care staff sat with the people in the lounge and played games, sang along with the people and chatted to them. On, another unit people were ambulant and they made arrangement to do things themselves with the help of the care staff. However, two of the four unit staff were unable to attend to peoples’ social and recreational needs due to the dependency levels of the The Abbeys DS0000003069.V363819.R02.S.doc Version 5.2 Page 14 people using the service and the staff having to spend most of their time delivering care. We discussed this with the management at the feedback. We spoke with the visitors and people using the service who assured us that the staff and the manager welcome visitors and were friendly towards them. Three people using the service made the following comment to confirm that they were helped by the staff to exercise choice and have control over their lives. “I do my own shopping or get the staff to help me with shopping so that I can get my favourite things.” “I visit my mother most days. She gets up very early in the morning and likes to have a sleep during midmorning. The staff are good they make sure she gets a ‘cuppa’ when she gets up.” “I don’t like doing much. I read and like to spend time in my room. The staff let me do what I like during the day.” We observed people having lunch. The staff were helping people choose their meals and assisted them. Meals were not hurried and people were offered a second helping if they so wish. One relative said, “My A is not a big eater but A gets a good diet. The staff are good at making sure A gets something to eat every mealtime.” The Abbeys DS0000003069.V363819.R02.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&18 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. The people using the service are able to express their concerns and have access to a complaints procedure. The people using the service and the staff working at the home are protected from abuse by the home’s policies and staff awareness and training. EVIDENCE: The complaints policy was available to people using the service and the staff. Two people said that they did not feel the need for formal complaints. They spoke to the staff or the manager if they wanted to raise any concerns. Three staff interviewed knew the homes complaints policy and they said that they were competent to deal with complaints. All staff we spoke with had received training on safeguarding adults and Protection Of Vulnerable Adults. We checked the training records of four staff and there was documentation to support this. The Abbeys DS0000003069.V363819.R02.S.doc Version 5.2 Page 16 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, 20,22,24,25& 26 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. The physical design and layout of the home enables people who use the service to live in a safe, well-maintained and comfortable environment, which encourages independence. EVIDENCE: We made the following observations. The grounds surrounding the home were kept safe and attractive. The people were able to access and enjoy the outside if they so wish. The manager informed us that she was in the process of putting together a programme for maintenance, renewal of fabric and decoration of the premise for this year. (The company year runs between September to the next August.) There was plenty of space for socialising, cultural activities and dining. We observed the people using these facilities on the day of our visit. The Abbeys DS0000003069.V363819.R02.S.doc Version 5.2 Page 17 We saw people sitting in a line, facing the TV and the fireplace in one of the sitting rooms, which was attached to the dining area. On questioning, the staff explained that the people often got up to move elsewhere and since the majority of them were infirm and unsteady having an open areas with few obstacles helped them mobilise safely and had reduced the risk of the people meeting with accidents. During staff interviews they informed us that they had the necessary equipment such as hoists and aids, so that they were able to meet the needs of the people using the service. The individual rooms were accessed with the permission of the people using the service and the manager accompanied us. The rooms were personalised and the people seemed contented living at the home. One person said that she/he had lived there since new and liked it very much. They spoke well of the manager and the staff. During our tour we observed that there was provision for emergency lighting throughout the building. The laundry facilities were sited away from the cooking area. The laundry was manned during the morning and there was sufficient number of washing and drying machines. The Abbeys DS0000003069.V363819.R02.S.doc Version 5.2 Page 18 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&30 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. The staff working at the home are trained and skilled to support the people who use the service. However, the staffing levels and the skill mix on the whole does not reflect the dependency levels of the people using the service and is therefore unable to support the smooth running of the service. EVIDENCE: The staff rota showing which staff were on duty during the day and night was kept on each unit. During our tour we observed the staff interactions. We consulted the people using the service about how accessible the staff were. The comments centred around the lack of staff to cope with the increasing needs of those who live at the home. During feedback we spoke with the management with regards to the above and we were assured that they would be looking into this. We were informed that the nurses and the senior carers continue to go in earlier to receive handover from the staff going off duty; so that they are able to organise and inform the next shift. The staff also confirmed that they did not get paid for their meal breaks but often they did not get the full break due to pressures at work. We received this information following our site visit. The Abbeys DS0000003069.V363819.R02.S.doc Version 5.2 Page 19 Four staff training records were checked. These staff have had all the necessary training and updates sessions where applicable to ensure that they were competent to do the jobs. Four staff recruitment files were also checked. The evidence showed that the registered manager operated a thorough recruitment procedure based on protecting the people using the service and those who work at the home. The Abbeys DS0000003069.V363819.R02.S.doc Version 5.2 Page 20 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): 31,33,35,36&38 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. The management of the home is based on respect and good communication with people using the service and the visitors. The quality assurance systems in place are effective and help to improve the service. EVIDENCE: The registered manager is experienced and has established clear lines of accountability within the home. She and her senior staff were working to achieve the best for those who live at the home by regular audits and meetings with the people using the service and the staff. The findings from the audits and meetings were analysed by the management to make improvement to the service. The Abbeys DS0000003069.V363819.R02.S.doc Version 5.2 Page 21 One of the changes was that the care practices at the home have moved towards focusing on the best outcome for those who live there. For example to embrace peoples’ individual routines and person centred life style the key workers needed to organise care and the activities for small groups of people. This aspect of our finding triggered the management discussion for the need to rethink the key workers sharing the activities for people instead of a coordinator trying to accommodate several peoples’ needs. The administrator deals with the accounting and the fees. The people using the service had their own families or advocates dealing with their personal finances. During staff interviews they informed us that they received regular supervisions (they called it 1:1). The manager showed evidence of documentation of staff supervisions. The registered manager and her senior staff made sure people living and working at the home were safe by training, auditing and ensuring regular maintenance is carried out. The manager reported any accidents or incidents that occurred at the home to the Commission for Social Care Inspection and the other relevant authorities. The manager said that they were in the process of reviewing their induction training. One care staff said that s/he received induction training before left to work on his/her own. The Abbeys DS0000003069.V363819.R02.S.doc Version 5.2 Page 22 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 3 3 3 x 3 x 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 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 x 3 x 3 3 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 3 x 3 The Abbeys DS0000003069.V363819.R02.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No 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 OP27 Regulation 18,16 Requirement The management must ensure that the staffing numbers on each unit reflect the dependency levels of the people using the service. The staff must be given time to attend to the personal, social and recreational needs of the people whom they are responsible for. Timescale for action 05/11/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 7. Refer to Standard OP27 Good Practice Recommendations The staff should be allowed formal time for the handover between shifts and the management should not expect the staff to come earlier in their own time in order to take handover. This is an ongoing recommendation and very little progress has been made. The Abbeys DS0000003069.V363819.R02.S.doc Version 5.2 Page 24 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 The Abbeys DS0000003069.V363819.R02.S.doc Version 5.2 Page 25 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!