Inspection on 12/06/08 for Avala Park

This inspection was carried out on 12th June 2008.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Avala Park 16/09/09

Avala Park 13/06/07

Avala Park 13/11/06

Avala Park 10/01/06

Avala Park 15/08/05

Avala Park 20/10/04

Avala Park 21/06/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Avala Park Mile Road Widdrington Morpeth Northumberland NE61 5QW Lead Inspector Anne Urwin Brown Unannounced Inspection 12th June 2008 09:30 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 Avala Park DS0000000553.V366953.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Avala Park DS0000000553.V366953.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Avala Park Address Mile Road Widdrington Morpeth Northumberland NE61 5QW 01670-790019 01670 791203 avalapark@highfield-care.com 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 Care Homes Limited Mrs Alison Martin Care Home 35 Category(ies) of Dementia (11), Old age, not falling within any registration, with number other category (24) of places Avala Park DS0000000553.V366953.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 only - Code PC 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, maximum number of places: 24 2. Dementia - Code DE, maximum number of places: 11 The maximum number of service users who can be accommodated is: 35 13th June 2007 Date of last inspection Brief Description of the Service: Avala Park is a purpose built two-storey home located in the rural village of Widdrington. The home is set back from the road in its own large gardens and it has ample car parking space. Local amenities and public transport are limited but include a small supermarket, public house, community centre and GP surgery. The home is registered to provide accommodation and personal care to 35 older people, 10 of whom have a dementia. Southern Cross Care Homes Limited owns the home. Fees range from £419.08 to £463.58 per week. The statement of purpose, service user guide and copy of the most recent inspection report are available at the home. Avala Park DS0000000553.V366953.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating of this service is 2 star. This means that people using this service experience good quality outcomes. How the inspection was carried out Before the visit: We looked at: • Information we have received since the last visit on 13th June 2007. • How the service dealt with any complaints & concerns since the last visit. • Any changes to how the home is run. • The provider’s view of how well they care for people. • The views of people who use the service & their relatives, staff & other professionals. The Visit: An unannounced visit was made on 12th June 2008 for seven hours starting at 08:50 am. During the visit we: • • • • • • Talked with people who use the service, relatives, staff, the manager & visitors. Looked at information about the people who use the service & how well their needs are met, Looked at other records which must be kept, Checked that staff had the knowledge, skills & training to meet the needs of the people they care for, Looked around the building/parts of the building to make sure it was clean, safe & comfortable, Checked what improvements had been made since the last visit. We told the manager/provider what we found. What the service does well: The needs and wishes of each person living at Avala Park have been properly assessed before they moved into the Home. This meant that staff knew about the needs of each person and what care and support they required. Good plans of care and risk assessments are completed for most people. This meant staff had the information they needed to support each person. Avala Park DS0000000553.V366953.R01.S.doc Version 5.2 Page 6 Peoples’ health care needs are met by good care practice and effective joint working with health professionals. People are encouraged and supported to make decisions about their daily lives and preferences so that they retain their independence and individuality. People living at Avala Park are encouraged and supported to maintain contact with their friends and family. The relationships between staff and people living at the home were good and personal support was provided in such a way as to promote and protect privacy and dignity. Complaints procedures are clear and people living in the home are made aware of them. Avala Park provides a homely and comfortable environment that suits the needs of the people living there. Staffing levels are adequate and appropriate training is provided to ensure that staff have the skills and knowledge to provide high quality care. Good systems are in place for auditing the quality of the service. What has improved since the last inspection? Peoples’ needs are fully assessed before they come to live at Avala Park and the information gained is use to plan their care. The recording of peoples’ changing needs has improved, but there are still some variations in the quality of recording in individual care plans and this means that some peoples’ needs and how these are met are not clearly identified. More activities are on offer and there is an activity organiser who takes responsibility for planning the programme. There were no odours evident during the inspection. New bedroom furniture has been purchased to replace damaged items, making the home safer and more comfortable. The laundry flooring has been replaced and vents have been fitted to the external door. Staff only leave the door open when they are in the laundry so that residents’ safety is not compromised. Bedside lights and bedside tables have been provided, however they are too large to fit in the space available in some rooms. Avala Park DS0000000553.V366953.R01.S.doc Version 5.2 Page 7 Furniture in the smoking room has been replaced. 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. Avala Park DS0000000553.V366953.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 Avala Park DS0000000553.V366953.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Clear and accessible information is available to enable people to make an informed choice, together with comprehensive assessments of need which ensure the service can effectively meet the persons needs. The home does not offer intermediate care. EVIDENCE: The service user guide is comprehensive and contains all of the information identified in Schedule 1 of the Care Standards Regulations 2001. It includes clear information about the service offered by the home including information about staffing, social activities, arrangements for religious observance as appropriate, fire safety, complaints, care planning, and the environment. Residents and their representatives are encouraged to visit the home and Avala Park DS0000000553.V366953.R01.S.doc Version 5.2 Page 10 spend time, this results in them having good information on which to base their decision to move into the home. One resident said that she thought that she had enough information before making a decision about coming to live at Avala Park. Three relatives returned questionnaires and they said that they felt there was enough information supplied by the home to make informed decisions. The care plans contain comprehensive pre-admission assessments, which are completed by the Manager or the senior staff. Care management assessments are also available. The information from these documents is used to develop individual care plans. All of the care plans looked at had these in place. Two residents said that they felt staff knew about their needs when they came to live at Avala Park. Intermediate care is not provided at Avala Park. Avala Park DS0000000553.V366953.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10 were inspected. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of care planning has improved and generally gives a good level of information to staff so that they can meet the needs of the people living at Avala Park. Care is planned with people in way that they prefer and in a sensitive manner. EVIDENCE: Each resident has an individual plan of care that is based on the admission assessment and this is added to during the placement. Care plans contain relevant information and systems are in place for regularly assessing individual needs for nutrition, skin care, moving and assisting, and continence promotion as well as a dependency rating. There are still some variations in the quality of recording and some examples of very good recording of individual needs and how these are met. More consistent monitoring of care planning is needed to ensure all care plans maintain the same standard of recording. Five people said that they are very satisfied with the care they receive, and that staff are Avala Park DS0000000553.V366953.R01.S.doc Version 5.2 Page 12 caring and kind. Staff are well informed about individual needs and demonstrated this during the inspection. Peoples’ health care needs and any specific treatments are generally well recorded and clear information was available about how staff support individuals. Visits by the doctor, district nurse and other health care professionals are recorded in individual records showing any treatment provided or advised. People said that they could see the doctor when they needed to. A hoist and other equipment is available for those who need it. Residents said that the staff are aware of their health needs. One relative and five service users said they were satisfied that there is access to the health services that needed. The systems for managing medicines in the home are in line with safe working practice guidelines. The records relating to the administration of medicines are generally completed and staff are clear about the procedures. Staff training has been provided for all staff involved in giving out medicines. Storage arrangements for medicines are satisfactory. Systems are in place for risks to be assessed if people want to manage their own medicines and lockable storage is provided. Residents said that the staff treated them very well, one person said that the staff were “know what I need help with and are always cheerful and nice”. Staff had a good rapport with residents. Evidence was available from care plans to show that people’s individual needs are identified and met. Staff are aware of equality and diversity issues when providing support to individuals. Relatives were positive about the support that staff gave and one said “I am very happy with my father’s care and well being.” Another comment was “Staff are very helpful and respect my father’s choices.” Staff guidance refers to equality and diversity and there is an emphasis on providing individualised care that takes account of peoples’ lifestyle and relationships. Avala Park DS0000000553.V366953.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are actively encouraged and well supported to continue to make decisions affecting their daily lives. This ensures that people maintain levels of autonomy and independence as long as possible. EVIDENCE: People living at Avala Park said that they are able to make choices about their daily routines, like when they get up, go to bed and what they do with their time. Individual routines are identified within most care plans. There is a programme of activities. An activity co-ordinator is employed who arranges most of the activities. Records show what peoples’ interests are and how they like to spend their time. During the inspection it was observed that people are encouraged to make choices about where and how they spend their time. There are videos, music tapes, newspapers and books available. Two people said they much preferred spending time in their rooms where it was quiet and they could read or watch television. Avala Park DS0000000553.V366953.R01.S.doc Version 5.2 Page 14 People living in the home said that they have regular visitors and this was evident from the visitors book and from talking to people living in the home. Information about arrangements for visiting is provided for people before they move in. Relatives questionnaires showed that they thought staff were welcoming and they (staff) “Give reassurance, calm and helpful in crisis times.” One relative said “We believe they (the staff) all do a super job, we are always made to feel welcome.” People are encouraged to continue to manage their finances for as long as they are able and this was evident from care plans. Staff encourage people to bring in furniture, ornaments and pictures from their previous homes. Rooms are personalised and reflect peoples’ interests and taste. People are able to follow their own religion and local ministers visit the home regularly. The menu shows that a varied diet is provided that offers choice at each mealtime and these are regularly reviewed. A new menu planning system has been introduced to ensure that peoples’ nutritional needs are catered for. Peoples’ likes and dislikes are recorded and staff ask for comments about the food. Positive comments were made by people living in the home during lunch about the quality of the food and the choice available. During the inspection six residents said that they were happy with the food and the choice provided. The food was well presented and cooked at the mealtime during the inspection. Staff have completed Food Hygiene training. Records show that there are regular cleaning routines and temperature checks of food and fridges. Avala Park DS0000000553.V366953.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A satisfactory complaints procedure is in place to ensure that complaints are dealt with effectively and to the satisfaction of the complainant. Good arrangements for protecting people using the service are in place. EVIDENCE: Guidance is available for dealing with complaints and the ethos of the home is to welcome complaints and learn from them. People living at Avala Park said that they knew how to make a complaint and that they felt able to speak to the Manager or the staff if they have any concerns. One person said that “the staff are always here and I can tell them if I have any concerns.” Four residents said that they would feel able to talk to the staff about their concerns or complaints and were satisfied that their concerns would be treated seriously. Three complaints have been made during the past year and records show a satisfactory investigation was carried out. All three complaints were upheld and action was taken to address these. Records of complaints are good and show that the home’s management takes seriously any complaints made. Staff knew how to help someone living at the home to make a complaint. Staff guidance provides clear information for staff about protecting people living in the home from harm. A copy of the Local Authority Safeguarding guidance is available in the home. People using the service are made aware of Avala Park DS0000000553.V366953.R01.S.doc Version 5.2 Page 16 what abuse is and the safeguards in place for their protection. Access to external agencies is promoted. Staff were clear about the procedures to be followed if an allegation is made. Training has been provided for twenty staff in safeguarding vulnerable people and further training is planned for other staff. One referral has been made to the Safeguarding Team of the Northumberland Care Trust and this matter is ongoing. Appropriate action has been taken with regard to this by the home. Avala Park DS0000000553.V366953.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 20, 21,25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The building is clean and generally well maintained which ensures that people live in a comfortable environment conducive to meeting their needs. Some refurbishment has resulted in a more comfortable setting for people living in the home. EVIDENCE: The home is spacious and there is a large sitting area near the front door with access to a conservatory that overlooks the gardens. Since the last inspection new lounge furniture, some new soft furnishings and carpets in communal areas have been purchased as part of the planned programme of refurbishment. The lighting has also been improved. The dining area is well furnished and appointed. People have access to specialist equipment and aids that are necessary to help them live as independently as possible. There is a Avala Park DS0000000553.V366953.R01.S.doc Version 5.2 Page 18 shaft lift fitted at Avala Park that provides good access arrangements for people with physical disabilities. The garden is accessible and provides a very attractive area for residents when the weather is suitable, however it is not secure and some residents are unable to use it without staff supervision. There is level access to the garden from the home. Parking is available at the side of the building. Storage space is limited throughout the home and the manager said that this can be a problem. The manager said that repairs are generally addressed quickly by the handyman, although there have been problems with the hot water system that have not been resolved. Rooms 12, 13, 15, 17 and 18 have no hot water at the time of this inspection and staff report that this has been an ongoing problem. Some rooms have a poor water pressure. Maintenance checks are carried out regularly and records were in good order. One person said “My room is comfortable and I have brought things in from my own home so it feels more homely.” One bathroom on the first floor has been made into a well appointed shower room that residents are regularly using. The other bathroom on the first floor has limited space and residents who need assistance use the bathroom on the ground floor regularly. The ground floor bathroom decor is shabby, the flooring is marked and worn and the rubber bath mat needs replaced as it is discoloured and worn. Aids and adaptations are fitted to maximise peoples’ independence apart from in some toilets there is no toilet raise for ease of use. Bedrooms are mostly well decorated and maintained. Five rooms have ensuite toilet and wash hand basin. New bedroom furniture has been purchased since the last inspection, however the problem of having a bedside cabinet has not been resolved. Bedside lights are now available, but the cabinet to stand them on does not fit the space available. Individuals are encouraged to bring items from their previous home. The laundry is well equipped with washers and a dryer, although it is very cramped and the only ventilation is through vents in the external door. The hot water cylinder is in the middle of this small room and space is very limited. Staff have had infection control training. There is a Belfast sink in the laundry, but no sluice facilities are available. This could compromise infection control. No odours were evident in the home during the inspection. Avala Park DS0000000553.V366953.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30 Quality in this outcome area is (excellent, good, adequate or poor). This judgement has been made using available evidence including a visit to this service. Staff numbers are adequate to meet the needs of the people living at Avala Park. Opportunities for training are good and this enables staff to learn new skills to better support the people living at the home. Good recruitment procedures protect people living at the home from harm. EVIDENCE: The service has appropriate numbers of staff at all times to support the needs of the people living at Avala Park. There is a settled staff team who work well together and support each other. Staff members’ roles and responsibilities are clearly defined and understood and appropriate job descriptions support this. People who use this service and their relatives spoke highly of the staff and one relative said “…all the staff carers, cooks, cleaners and management go out of their way to make all who live within those walls feel that it is ‘their’ home.” Another relative said “It is reassuring to know that Avala Park have a number of staff who have worked there for a long time. I believe that this continuity/ability to retain staff is a positive sign.” Staff training is targeted and prioritised to allow staff to undertake training beyond basic requirements. All care staff apart from two new staff have completed national qualifications in care. A level of 91 of trained staff has Avala Park DS0000000553.V366953.R01.S.doc Version 5.2 Page 20 been achieved. Staff said that they get enough training opportunities. Records show that mandatory training is provided as appropriate. Induction training is provided for all new staff and staff said that new staff are well supported to ensure that they are competent to meet residents’ needs. Equality and diversity issues are covered within training so that staff practice is improved. Staff records are completed in line with the company policies and procedures, including two references and a completed application form. The requirement to have a CRB and POVA check in place is applied to all of the staff in the home. Equality and diversity policies are reflected in recruitment and employment procedures and the Human Resources department carry out equality monitoring and maintain information in respect of staff employed. Records show that all checks are carried out and recorded to ensure that staff appointments are only made after the management has satisfied itself that applicants have the appropriate qualities to fully meet the needs of people living at Avala Park. Avala Park DS0000000553.V366953.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are good management systems in place to make sure that the home is managed effectively taking into account the needs and wishes of the residents. EVIDENCE: The manager is experienced in the care of older people and has the Registered Manager’s award. She undertakes regular training to keep up to date. There are good systems for auditing of the quality of the service provided. These audits together with resident questionnaires and regular resident meetings provide evidence of a quality assurance system that is customer focussed. Questionnaires for relatives show that they feel able to approach Avala Park DS0000000553.V366953.R01.S.doc Version 5.2 Page 22 staff and the manager at any time with any issues they may have about the care of their relative. Formal supervision for care staff is up to date and staff said that they are well supported by the management team. Practice and performance are discussed at supervision and training needs are identified from this. Regular staff meetings are held and staff said they are encouraged to contribute. Staff said that they had felt well supported when the home was taken over by the manager and the new management. There are effective systems in place for safeguarding and managing money held on behalf of people living in the home including clear records. People using the service or their relatives have access to the records whenever they wish. Records show that training in health and safety matters is provided and individual training records reflect this. Staff said that they receive this training. Health and Safety checks are regularly undertaken and records were available to show good standards are maintained. Policies, procedures and risk assessments for safe working practices are in place to promote and protect residents and staff. Staff said that appropriate induction training is provided for new staff and records are in place to confirm this. Full details of accidents are kept and evidence was available to show these are monitored for trends. Avala Park DS0000000553.V366953.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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 2 X X 3 3 2 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Avala Park DS0000000553.V366953.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No Avala Park DS0000000553.V366953.R01.S.doc Version 5.2 Page 25 STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP7 Good Practice Recommendations Care plans should be regularly checked to ensure there is a good standard of clear recording to show what support is provided for individuals. The hot water system needs to be checked and any problems with supply of hot water or water pressure must be resolved. The provision of sluice facilities should be reviewed to ensure that infection control is not compromised. The ground floor bathroom needs redecoration and new flooring. The rubber bath mat should be replaced as it is marked. 2 OP21 3 4 OP26 OP21 Avala Park DS0000000553.V366953.R01.S.doc Version 5.2 Page 26 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 Avala Park DS0000000553.V366953.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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