Inspection on 12/06/06 for Avalon Care Home

This inspection was carried out on 12th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Avalon Care Home 15/09/09

Avalon Care Home 21/04/09

Avalon Care Home 14/10/08

Avalon Care Home 08/05/07

Avalon Care Home 06/12/05

Avalon Care Home 15/06/05

Avalon Care Home 22/02/05

Avalon Care Home 08/09/04

Similar services:

Chirnside House

Keer Sands Residential Home

Sunny Bank (P.R.S.) Ltd

Ruskin Lodge

Bushell House

Ashwood Court Unit 1

Langrigg House

Parkside

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

CARE HOMES FOR OLDER PEOPLE Avalon Care Home 24 Duke Street Southport Merseyside PR8 1LW Lead Inspector Mr Paul Kenyon Unannounced Inspection 09:30 12th June and 5th July 2006 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 Avalon Care Home DS0000061380.V298124.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. Avalon Care Home DS0000061380.V298124.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Avalon Care Home Address 24 Duke Street Southport Merseyside PR8 1LW 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) 0151 200 8841 0151 200 8841 Avalon Residential Homes Ltd Ann Louise Wilson Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Avalon Care Home DS0000061380.V298124.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The service should employ a suitable qualified and experienced manager that is registered with the CSCI Twenty (20) places are to be registered in the category of OP Date of last inspection 6th and 20th December 2006 Brief Description of the Service: Avalon Residential Care Homes Ltd purchased Avalon care home in July 2004. Avalon is a Residential Care Home, which provides personal care and support for up to twenty elderly residents. Nineteen service users were resident at the time of the inspection. Ann Wilson manages the home. The home is a large detached converted house, set in a residential area, within walking distance of all the amenities of the town of Southport. Access to the town can be made via the local transport services where necessary. A lift provides access to all floors of the home. There is a large dining/ lounge area, a smoking room and gardens to front and rear, which can be accessed via the basement. Fees for the service are currently charged at £325 per week. Avalon Care Home DS0000061380.V298124.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was a key inspection and the home did not have any warning of the inspection beforehand. The inspection was spread over two days. The first day included a tour of the building as well as an examination of paperwork linked to the care of older people. The second day included interviews with six residents and two staff members. A number of comment cards were left for relatives to complete if they so wish. One relative took this opportunity and comments are included within the report. In total the inspection took 8 hours. National Minimum Standards for Older People were used in assessing the care provided to those living at Avalon. What the service does well: The service is good at ensuring that the needs of residents are assessed before they come to live in Avalon. The service is good at identifying the health needs of residents in particular their psychological health. The service is good at ensuring that the privacy and dignity of residents is maintained. The service is good at ensuring that residents are able to maintain contact with their families. The service is good at ensuring that residents have access to advocacy services and ensuring that those who cannot deal with their own finances have these dealt with by an independent person. The service is good at providing nutritious food that is linked to the dietary needs of residents. The service is good at ensuring that systems are in place to protect residents from abuse. The service provides an environment that is being continually improved and is clean and hygienic. Avalon Care Home DS0000061380.V298124.R01.S.doc Version 5.2 Page 6 The service is good at maintaining staffing levels and demonstrates a commitment to training and ensuring that staff obtain the qualifications needed to perform their role. The service is managed by an experienced individual who is aware of the needs of older people. The service assists in ensuring that any finances given to them on behalf of residents are accounted for. Comments from residents during the inspection included: ‘We get our privacy-staff always knock on the bedroom door’ ‘We always get treated with dignity’ ‘The food is good here, we get plenty of food’ ‘We have been getting lots of drinks during the hot weather’ ‘Staff are helpful’ ‘We are quite happy with the building, we have got new lounge chairs and we are getting new windows, we are pleased with our bedrooms’ ‘On the whole we are happy’ ‘If you need a Doctor they sort it out with no messing around’ One relative returned a comment card. Comments included: ‘My relative has all the medical support they need’ ‘My relative enjoys meals very much’ ‘My relative has said that they are very happy at Avalon and speaks very highly of the staff’. Other comments are included within the main body of the report. What has improved since the last inspection? A number of requirements raised at the last inspection have been met. All residents now have care plans. The service has now removed a headboard from a bed that was potentially a risk to the resident concerned. An offensive odour in one bedroom has now been eradicated. The home has now contacted an Occupational Therapist with a view to assessing the bathing needs of residents. The service has now put a lock on the door to the cleaning cupboard although cleaning materials have now been safely moved elsewhere. Avalon Care Home DS0000061380.V298124.R01.S.doc Version 5.2 Page 7 The service has now developed risk assessments for risks faced by residents in their daily activities. A certificate confirming the safety of the electrical wiring in the building has now been produced. 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. Avalon Care Home DS0000061380.V298124.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 Avalon Care Home DS0000061380.V298124.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 is not applicable to Avalon at present. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service Residents benefit from having their needs assessed and determined before they come to live at the home. EVIDENCE: Since the last inspection only one person had been admitted albeit on a respite basis. This short break was coming to an end on the first day of the inspection. The individual’s file was examined and evidence was available to suggest that needs of the person had been assessed by a Social Worker and the assessment had been obtained prior to the residents coming into the home for the short break. This enabled the home to make a judgement on whether the needs of the individual could be met. Avalon Care Home DS0000061380.V298124.R01.S.doc Version 5.2 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents and their representatives are not always involved in confirming the contents of their care plan. Residents benefit from having their health needs met. Residents do not benefit from a completely accountable medication system. Residents benefit from having their privacy upheld and consider that they are treated with respect. EVIDENCE: Six care plans were examined in detail as well as confirmation made during the inspection that all other residents had a care plan. The first day of the inspection noted that a new system of recording daily records had been introduced yet care plans appeared to be incoherent and not organised. This had been addressed by the second day of the inspection. All residents have a care plan which includes the information needed to support that person effectively. Two members of staff were able to confirm that they had access to care plans and all care plans are securely stored yet available to staff when needed. No information about the religious needs of residents was included in Avalon Care Home DS0000061380.V298124.R01.S.doc Version 5.2 Page 11 care plans. The completion of this information is raised as a recommendation in this report. All care plans examined showed evidence that the plan had been reviewed as recently as June 2006 with the next date for review (July 2006) identified on the plan. Daily records are now computerised although hard copies are placed in care plans for reference. These records are not directly signed by the staff completing them. It is recommended that staff sign these records to confirm that they are the authors of the comments. The content of daily records is such that this supplements the care plans and identifies the progress made by individual residents. Care plans are slowly being signed by residents or in most cases by relatives or other professionals to confirm that they agree with its contents. This has not been extended to all with the result that residents or their relatives currently do not receive an equal opportunity to agree with the support provided. This is raised as a requirement in this report. For the purposes of assessing health needs, two residents were case tracked, in particular the maintenance of their psychological health. Files suggested that both individuals were receiving support from community nursing services and care plans signed by members of these services confirmed that they agreed with contents. Other evidence suggested that appointments with these individuals continued and outcomes were also available. One resident commented that ‘if you need a Doctor, they get one with no messing around’. This suggested that the service dealt with any health problems as quickly as possible. One relative stated through a comment card that ‘the person gets all the medical support they need’. Evidence on a yearly planner identified future appointments for residents, usually hospital visits set up for the next few months. Weight is monitored on a periodic basis. The home has purchased a weighing chair for this purpose and evidence was available to suggest that recent weight monitoring had occurred. The records did not indicate whether there had been any change in the weights of individuals since the last time given that the format of weight recording did not provide the opportunity to do this. It is recommended that this be done. The initial inspection noted that the medication trolley was positioned in the dining room when not in use and was not secured to the wall. In addition to this, the positioning of the trolley was potentially impeding anyone who wanted to use the passenger lift. By the second day of the visit, this had been addressed. The medication trolley had been repositioned to an area where it Avalon Care Home DS0000061380.V298124.R01.S.doc Version 5.2 Page 12 has been stored during past inspections and securely tethered. The trolley is kept locked when not in use. Records initially suggested that medications received had not been confirmed through signatures. This matter was not initially raised after the first inspection day yet the second visit noted that this had been done with the amount of medication received confirmed through signatures. Medication records suggested that not all administration of medication could be confirmed through signatures in all cases. For the most part this had been done yet omissions still occurred. As a result there was no evidence if medication had been administered or not and if it had not been, the reasons for non-administration were not clear. This is raised as a requirement in this report. The Manager confirmed that she was aware of this situation and was seeking to take action to address this. The Inspector spoke with two members of staff. Both confirmed that they had recently attended medication awareness courses in June 2006. Certificates had yet to be issued. Six residents were asked about privacy and dignity. All confirmed that they considered that staff upheld their privacy. One resident did state that they did not have a key to their room. Further information was provided to suggest that a risk assessment had been done which confirmed reasons why a key had not been issued. This risk assessment and others were viewed during the inspection. All residents confirmed that staff knocked on their bedroom doors before entering. This was directly witnessed during the inspection. Other issues relating to privacy included locks on toilet and bathroom doors and arrangements for opening mail. During the inspection, the post had arrived and one resident was witnessed asking a staff member to read the contents of the letter to him because of certain learning needs that the person had. This was done in complete privacy. All terms of address are identified in the care plan. Clothing is organised in the laundry in such a manner to avoid the wrong clothing being passed to residents and all clothing is discreetly marked. Avalon Care Home DS0000061380.V298124.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents do not consider that they are able to be involved in the activities they wish but do benefit from having their daily, preferred routines respected. Residents benefit from having continued contact with their family and friends. Residents benefit from having access to advocacy service if they so wish and retain independence as far as possible. Residents benefit from a service that provides a good standard of food. EVIDENCE: Six residents were asked about activities in the home. Some were either not clear about what was provided with others stating ‘there is nothing much to do’. Some stated that there had been an in house entertainer some time ago. This led to further comments from some residents about the level of involvement they had in the home. This is outlined in Standard 33 of this report. One comment card returned by a representative stated that ‘activities were usually arranged’. In addition to this, records recently started by the service suggested that trips to town and a mobile cinema had been recently provided. This conflicted with the views of residents. Avalon Care Home DS0000061380.V298124.R01.S.doc Version 5.2 Page 14 All residents confirmed that they were able to ‘get up when I want or have a lie in’ and ‘ I get up early anyway and I always have’. Residents also confirmed that they were able to receive visits from their families on a regular basis ‘they come when they want, there are no limits on this’. The dependency of many residents is such now that issues such as managing their financial affairs had been transferred to their families. One resident in the past had outlined to the Inspector how he had managed his own monies. His needs had now changed to the extent that he confirmed that his family assisted with this. Independence in financial affairs is met given that where individuals are no longer able to deal with their own finances, families are able to play a role with the services only involvement in this being the opportunity to safe keep monies in an accountable fashion as outlined in Standard 35 of this report. One person currently receives advocacy services and this is ongoing. Information about advocacy is available in the home. Comments in respect of food included: ‘The food is good’ ‘Food is ok’ ‘We get plenty to eat’ ‘There is usually two much food’ ‘We get cooked meals and occasionally a sandwich’ ‘We have been getting plenty of drinks during this hot weather’ The inspection coincided with a spell of very hot weather. At the beginning of the second visit, all residents had been offered cold drinks, a little later on a choice of hot drinks had also been offered yet residents confirmed that drinks had been available at al times. One relative comment card stated that ‘my relation enjoys the meals very much’. The Inspector had discussions with the cook. Menus run over a two-week period. The cook had stated that this did not provide a variety of food and had consulted with residents about extending the menu to a 31-day cycle. He stated that residents had welcomed this. In addition to this, this exercise had allowed a determination of the preferences of residents to be gained. Care plans suggested that two people have a health condition that means that they require a certain diet. The cook was able to confirm the identity of these individuals. Food stocks were noted to be adequate during the visit. No external supplier is used and the Manager and one of the Directors of the organisation that runs Avalon purchase all shopping from local supermarkets. The cook stated that the Manager and Director were very good and that anything that was needed was bought. Avalon Care Home DS0000061380.V298124.R01.S.doc Version 5.2 Page 15 Since the last inspection, a lounge has been converted into a dining room. The home has never had a dining area as such so this is an improvement in the facilities. Not all residents can be accommodated here yet the area is still retained as a lounge for times other than meal times. This area has been redecorated and is home like in appearance. Avalon Care Home DS0000061380.V298124.R01.S.doc Version 5.2 Page 16 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents are unclear about where to go if they have any concerns about the service. Residents are protected from abuse. EVIDENCE: The complaints procedure has been used by external agencies since the last inspection. A complaint was raised and passed to the provider for investigation yet was not upheld and there has been no indication since that the complainant is satisfied or otherwise with this response. A comment card completed by a relative stated that they were clear about who to approach if they had a complaint. Residents were asked who they could go to if they had a complaint. No person stated that they had a complaint but were very unclear what they would do if they had. Only one person stated that they would see the Manager. Given this it is recommended that the complaints procedure be reinforced to residents. This should be linked to a requirement in relation to consulting with residents outlined in Standard 33 of this report. Since the last inspection, the service has received an allegation. Action was taken at the time to protect the resident and the matter was referred to the Local Authority Social Services Team. As a result the Manager has been able to demonstrate her awareness of the procedure for safeguarding service users. The Manager has also been in the process of referring a former staff member to the Protection of Vulnerable Adults register and is aware of the requirements Avalon Care Home DS0000061380.V298124.R01.S.doc Version 5.2 Page 17 of this. The Manager has not got a copy of the Local Authority procedure for referring abuse allegations. It is recommended that be obtained. Two members of staff were interviewed. Both were able to confirm that they had attended abuse awareness training and were familiar with the whistle blowing procedure as well as the role that the Commission for Social Care Inspection had in this. Avalon Care Home DS0000061380.V298124.R01.S.doc Version 5.2 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents benefit from an environment that is well maintained, subject to continued refurbishment and is clean and hygienic. EVIDENCE: The Directors and Manager of the home have been operating the home for two years and this is taken in the context of the general refurbishment that was needed at that time. The home has been refurbished to a good standard and this continues. Since the last inspection, a bathroom has been refurbished and plans are in place to extend this to the assisted bath on the lower floor of the home. A lounge area has now been converted into a dining room and decorated appropriately. Many bedrooms have bee redecorated and recarpetted and a programme of replacing exiting windows with UPVC frames is ongoing. During the inspection, a number of vertical blinds were being fitted Avalon Care Home DS0000061380.V298124.R01.S.doc Version 5.2 Page 19 in the home with a view to these being extended to all areas. Residents confirmed that they were happy with the environment and were aware of the improvement work that continued, in particular the replacement of window frames. The home has a large garden area to the front of the home, which receives significant sunlight in finer weather. Seating is available. Many residents took the opportunity to use this during the visit. One person who relies on a wheelchair was assisted by a staff member to gain access to this area and this demonstrated that all had equal access to the garden regardless of their mobility needs. CCTV cameras are in operation to the exterior of the house. This system is for security only and a view of monitors noted that resident privacy was not compromises or breached. A requirement at the last inspection noted that one bedroom area had an enduring offensive odour in it. This has now been eradicated with new flooring placed in this area. No other offensive odours were noted during the visit. A laundry area is available. This does contain two freezers yet plans to move these were independently confirmed by two staff members. The laundry is organised. A clinical waste system is in place and soap, towels and protective clothing is available throughout the building. Avalon Care Home DS0000061380.V298124.R01.S.doc Version 5.2 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents benefit from the numbers of staff on duty. Residents are not protected by the recruitment procedure. Residents benefit from receiving support from a trained staff team that is undertaking the qualifications needed to do the job. EVIDENCE: Staff levels during both days of the inspection included: 1x 1x 2x 1x Manager Senior Care Assistant Care Assistants Cook In addition to this, both Directors of the operating company were on site attending to refurbishment work. Staffing levels as a result are maintained. A staff rota is available which suggested that these staffing levels continue and rotas are prepared in advance. Residents stated that ‘staff were helpful and treated you with dignity’. A comment card returned by a relative stated that ‘staff listen and act on what is said’ and that ‘they are usually available when I need them’. Avalon Care Home DS0000061380.V298124.R01.S.doc Version 5.2 Page 21 All staff with the exception of three have commenced NVQ Level 2. This represents at least 50 of staff who have commenced this. One member of staff was able to confirm that she had started the course and that some elements in respect of protection of vulnerable adults had been covered to supplement her abuse awareness training. A requirement at the last inspection highlighted the need for personnel files to include at least two references. The inspection also identified that personnel records appeared to be disorganised. This visit noted that a lot of work had been done to keep files confidential and to obtain the necessary per employment checks such as ‘POVA first’ to enable a view of the fitness of staff to be determined. One file relating to a new member of staff noted that only one reference had been obtained. This remains a requirement in this report. Two staff members who had commenced employment since the last inspection were able to confirm that they had received the following training: Manual Handling Health and Safety First Aid Food Hygiene Infection control Medication training Fire awareness Protection of vulnerable adults awareness Dementia awareness Avalon Care Home DS0000061380.V298124.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33, 35 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents benefit from a service that is managed by an experienced individual. Residents are not always involved in the quality assurance process and consider that they need to be listened to more. Residents benefit from having their financial interests safeguarded. Health and safety systems in the main protect residents yet some environmental factors do put them at some risk. EVIDENCE: The Manager has been in post for two years having undergone the registration process with the Commission for Social Care Inspection. The Manager has the experience to perform this role. Avalon Care Home DS0000061380.V298124.R01.S.doc Version 5.2 Page 23 The quality of the care provided by the home is measured in a number of ways but is not equally inclusive. A quality assurance system is in operation from a local and independent agency. This was last completed in November 2005 and is carried out annually. The service has also issued questionnaires to all relatives in April 2006. Five relatives responded and all these were examined with no concerns identified. In addition to this, the home co-operated with the inspection enabling the Inspector to speak with staff and residents in private. In addition to this comment cards were left with the Managers agreement for relatives to complete if they wished. Discussions with residents included comments from them including ‘the home could do better’, ‘we want to be more involved’ and ‘we want to be listened to more’. Given these comments and given the differing evidence of activities and uncertainty about the complaints procedure, it is required that residents meetings are set up initially on a monthly basis. The majority of residents rely on family members to deal with their monies. Monies received are recorded and witnessed by two staff in most cases. Records did suggest that a minority of signatures were not made. The Manager is aware of this and has taken action. All monies that are put into safe keeping on behalf of residents are securely and individually stored. Records are maintained and receipts kept. A requirement at the last inspection highlighted the need for a certificate to be produced evidencing the safety of the electrical wiring of the home. This has now been done. In addition to this, risk assessments have now been completed in respect of the hazards faced by residents and staff in daily routines. Staff interviews confirmed that training had been received in respect of health and safety topics and these are outlined in Standard 30 of this report. New window frames have been put into position on a number of areas. These have window restrictors available. One room has no window restrictor in place. This is raised as a requirement in this report. In addition to this, a freezer has a lid that has become unattached from the main body of the freezer. This may cause food to defrost and may create a food hygiene hazard to stocks of frozen food. It is required that this is repaired or replaced. Avalon Care Home DS0000061380.V298124.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 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 2 17 X 18 3 3 X X 3 X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 2 X X 2 Avalon Care Home DS0000061380.V298124.R01.S.doc Version 5.2 Page 25 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement Residents and their representatives must sign care plans confirming their agreement with their contents Medication administration records must be signed with no omissions Residents meetings must be set up to determine residents preferences in activities, to enable residents to be aware of the complaints procedure and to ensure that residents’ views are included within the quality assurance audit A minimum of two references must be available on the personnel file identified at the inspection. A restrictor must be fitted to the bedroom window identified during the inspection The lid of the freezer identified during the inspection must be repaired or replaced Timescale for action 01/09/06 2. 3. OP9 OP12OP33 13 26 05/07/06 31/08/06 4. OP29 19 31/07/06 5. 6. OP42 OP42 13 13 05/07/06 31/07/06 Avalon Care Home DS0000061380.V298124.R01.S.doc Version 5.2 Page 26 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. 2. 3. 4. 5. Refer to Standard OP7 OP7 OP8 OP16 OP18 Good Practice Recommendations The religious or cultural needs of residents should be included within each care plan Computer generated daily records should be signed by staff once they are included within care plans The form for completing weight monitoring should be redevised to include weight change The complaints procedure should be reinforced to residents The Local Authority procedure for the reporting of abuse allegation should be obtained Avalon Care Home DS0000061380.V298124.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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