Inspection on 12/10/07 for Avalon Care Home

This inspection was carried out on 12th October 2007.

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 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

Avalon Care Home 20/02/09

Avalon Care Home 14/01/09

Avalon Care Home 03/10/08

Avalon Care Home 17/08/06

Avalon Care Home 16/12/05

Avalon Care Home 02/12/04

Avalon Care Home 03/06/04

Avalon Care Home 26/01/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Avalon Care Home 116 Clipstone Road West Forest Town Nottinghamshire NG19 0HL Lead Inspector Jayne Hilton Unannounced Inspection 12th October 2007 07:00 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 DS0000024627.V352841.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 DS0000024627.V352841.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Avalon Care Home Address 116 Clipstone Road West Forest Town Nottinghamshire NG19 0HL 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) 01623 644195 01623 429977 avalon@schealthcare.co.uk www.southerncrosshealthcare.co.uk Southern Cross Care Homes No 2 Limited Mrs Ann Elizabeth Barlow Ayodele Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Avalon Care Home DS0000024627.V352841.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service users shall be within category OP One named service user as applied for in application dated 16/10/05 may be within category PD 17th August 2006 Date of last inspection Brief Description of the Service: Avalon Care Centre is a purpose built two-storey, forty bedded care home for older people situated on the outskirts of Mansfield, close to the former mining village of Clipstone. It is situated on a main road, which has a public bus service, and is approximately two miles from Mansfield town centre to the North East. All bedrooms are single occupancy, with half having en-suite facilities. Avalon is close to local shops, and a pub. There is ramped access to the home and a passenger lift is installed. The range of fees were not detailed in the Service User Guide, however information supplied on the day of the inspection by the temporary manager detailed fees ranged between £290 and £504. No information was supplied as to extra charges. The Service User Guide stated that a copy of the previous inspection report was at the back of the documents, however this was not so, neither was a copy of the report displayed or any information posted informing service users or visitors to the home how they could access a copy. Service users, staff and a relative spoken with were not aware of the inspection reports or how they could access this. Avalon Care Home DS0000024627.V352841.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection is upon outcomes for service users and their views on the service provided. This process considers the provider’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provision that need further development. This inspection took place over 9.5 daytime hours and was conducted unannounced. Prior to completing this visit the inspector assessed the homes previous inspection reports, the service history including complaints and adult protection referrals. The main method of inspection used was called ‘case tracking.’ This involves selecting two service users and looking at the quality of the care they receive by talking to them, examining their care files and discussing how support is offered to them by staff members. Many of the people who live at this home have a very limited ability to understand and communicate. Therefore many judgements in this report are from observation and reading residents’ records and documents. The residents who were “case tracked” were not able to help by giving an opinion about the care provided. Seven service users who were not part of the case tracking provided other information during the inspection. Relatives were observed visiting the home but due to the focus of the inspection, comments from one relative only were obtained. Six members of staff and the temporary manager were also spoken with as part of this inspection, documents were read and medication inspected to form an opinion about the quality of the care provided to residents. . What the service does well: Avalon Care Home DS0000024627.V352841.R01.S.doc Version 5.2 Page 6 Service users health, personal and social care needs are set out in an individual plan of care their needs are assessed and they are provided with a contract. A service user confirmed that she had been able to stay for a short trial visit to the home before deciding to stay. Healthcare records and risk assessments were mostly satisfactory and there was evidence of specialist input such as the tissue viability specialist and appropriate equipment used for pressure area care and prevention. Nutritional screening had been undertaken for the two service users, case tracked and the home has introduced the ‘nutmeg’ system to ensure meals are nutritionally balanced. Service users were, observed to be asked, if they wanted more tea and they were supported appropriately and not rushed at meal times. Soft diets were served in an appetising way and there was a good supply of fresh vegetables and fruit. Service users said the food was lovely and confirmed they had choices. A service user confirmed that she was able to manage her own financial affairs and that she was able to bring her own possessions into the home. The numbers of staff provided currently meets service users needs and recruitment practices are satisfactory. Staff receive training in health and safety topics. Service users live in a clean, safe, well maintained environment. There was also evidence of some good care practice and that action is being taken to address practice issues within the home. Service users/representatives spoke highly of the staff team What has improved since the last inspection? A temporary manager is currently in post, who is clearly addressing some problems recently experienced by the home. Avalon Care Home DS0000024627.V352841.R01.S.doc Version 5.2 Page 7 What they could do better: Continue to improve the actions being taken to ensure that the home is being run in the best interest of service users. Improve the lifestyle experiences of service users and the promotion of their rights. The routines of daily living and activities need to be more flexible and varied to suit individual service users needs, preferences and capacities. Ensure that at all times Service users are treated with respect or their right to privacy upheld. Improve the systems in place for management of medication Improve the availability of keys to service users own bedrooms and lockable facilities. Ensure that there is always sufficient competent and qualified staff to meet service users needs. Further training covering the specific needs of service users is needed to improve the standard of care they receive and experience in the home. Create an environment whereby Service users and their relatives feel are to make complaints. The number of safeguarding adults investigations indicate that service users may not be fully protected from harm. More imaginative ways of engaging residents, particularly those with Dementia in purposeful activity need to be found to make sure they are not treated differently to other residents. There were six accident/incidents in respect of service users recorded in the homes records that had not been notified to CSCI. Improve the evidence of quality monitoring in the home. Avalon Care Home DS0000024627.V352841.R01.S.doc Version 5.2 Page 8 Eight requirements and ten recommendations are made in respect of the above. 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. Avalon Care Home DS0000024627.V352841.R01.S.doc Version 5.2 Page 9 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 DS0000024627.V352841.R01.S.doc Version 5.2 Page 10 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, 4 and 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users do not have all of the information they need about the home, but their needs are assessed and they are provided with a contract. Service users needs and rights are not being fully addressed and respected by staff. The home does not provide an intermediate care service. EVIDENCE: Copies of the homes Statement and Purpose and Service User Guide were displayed in the reception area, however there was no evidence that service users or their relatives are issued with their own copy as required by regulation. The Service User Guide stated that a copy of the previous inspection report was at the back of the documents, however this was not so, neither was a copy of the report displayed or any information posted informing service users or visitors to the home how they could access a copy. Service users, staff and Avalon Care Home DS0000024627.V352841.R01.S.doc Version 5.2 Page 11 a relative spoken with were not aware of the inspection reports or how they could access this. Service users/and or their representatives and the care records examined confirmed that an assessment had been undertaken of the persons needs. which included obtaining information about service users religious, cultural and social needs, and devising a plan of care for staff to follow, however there were several gaps in the paperwork that had already been identified in a recent audit undertaken by the company. A service user confirmed that she had been able to stay for a short trial visit to the home before deciding to stay. Contracts are issued, however the Service User Guide does not contain details of the fees charged. Wording in the Southern Cross Quality with Commitment booklet states, “We set ourselves high standards in every aspect of the care we deliver. We never forget our service users are individuals and they are treated with respect and dignity at all times” The overall findings of the inspection were, that although the service promises to deliver care to residents in a way which respects their personal dignity and right to privacy that this is not how some care is provided in practice. The Commission for Social Care Inspection found that there were low levels of staff interaction with the service users and the interactions, which were seen, were mostly of poor quality or to undertake tasks and these did little to enhance the quality of life of the service users. The comments from residents, staff and our observations provide ample evidence that the staffing levels at the home have not been sufficient in the previous two months, to enable staff to properly engage, support and provide positive and holistic care to the residents, particularly those with Dementia. However there was also evidence of some good care practice and that action is being taken to address practice issues within the home. Steps must be taken to make sure that service users are treated with dignity and respect by the staff at all times. Avalon Care Home DS0000024627.V352841.R01.S.doc Version 5.2 Page 12 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 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users health, personal and social care needs are set out in an individual plan of care, however they are not always treated with respect or their right to privacy upheld. Systems in place for management of medication require improvement to ensure service users are not placed at risk of harm. EVIDENCE: Care plans were in place but as already specified had been identified as incomplete records of the individuals care. Action had been taken by the temporary manager to ensure that care records were now being fully completed to ensure service users needs were being appropriately monitored and met. Avalon Care Home DS0000024627.V352841.R01.S.doc Version 5.2 Page 13 Individual care plans were recorded as reviewed on a daily basis, however there was sparse documentation on personal care charts and statements from service users/representatives and staff that service users had not had personal care such as a bath/shower for three weeks in some cases. Records from the end of September had however been completed and there was evidence that this was being monitored by the temporary manager and regularly audited. Two service users and a relative said they had not seen their care plan or been involved in their review. Healthcare records and risk assessments were mostly satisfactory and there was evidence of specialist input such as the tissue viability specialist and appropriate equipment used for pressure area care and prevention. Nutritional screening had been undertaken for the two service users, case tracked and the home has introduced the ‘nutmeg’ system to ensure meals are nutritionally balanced. Risk assessments were reviewed monthly. Records of foot care/ chiropody care were noted to be undertaken, but not always documented within the individuals care notes. A pharmacy inspection had been undertaken the day before the inspection, which highlighted that: Handwritten medication charts did not always have two witness signatures. Some doses had been signed for when medication had not been given- [refusal codes must be used]. One entry in the Controlled drugs register was not complete with two signatures. The medicines fridge needs to be defrosted. A bottle of Paracetomol with packet removed to be disposed of. Medication administration was observed on the day of the inspection as satisfactory in practice. [See also standard 18] Although service users/representatives spoke highly of the staff team and some said that their privacy and dignity was always maintained, there were examples of some poor practice in this area too. [Also see Standards3, 4 and 18 and 24] Avalon Care Home DS0000024627.V352841.R01.S.doc Version 5.2 Page 14 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 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The lifestyle experiences of service users and the promotion of their rights could be much improved; the routines of daily living and activities need to be more flexible and varied to suit individual service users needs, preferences and capacities. EVIDENCE: An activities co-ordinator is provided for thirty hours a week. Records were seen, of participation and refusal by service users of activities and one to one activities are provided two mornings a week. . We saw one to one craft activities during our visit but the activity programme seemed to be aimed at the more able residents, (for example dominoes, cards and bingo. Avalon Care Home DS0000024627.V352841.R01.S.doc Version 5.2 Page 15 More imaginative ways of engaging residents, particularly those with Dementia in purposeful activity need to be found to make sure they are not treated differently to other residents. Visitors were observed throughout the day and those spoken with said they were made welcome by staff. The home had a planned autumn fair, but there was limited evidence otherwise of community involvement. A service user confirmed that she was able to manage her own financial affairs and that she was able to bring her own possessions into the home. At the commencement of the inspection at 7am three service users were seated in wheelchairs at dining tables and one service user sitting in the lounge area. [Breakfast was not served until 8.30am] There were no care staff supervising service users in these areas, at this time as they were assisting service users to get up. The nurse was having her break then had to undertake paperwork. There was no radio or television on at this time and staff, were not heard to ask service users if they would like to watch or listen to either of these. Interaction/behaviour between some staff and a visiting contractor was noted to be loud, inappropriate and in disregard of the service user’s home and their presence. Interaction/engagement between staff and service users was minimal and in some cases none at all. Service users were not always informed where they were being taken in their wheelchairs, but there was also good practice observed for example service users were asked if they wanted more tea and they were supported appropriately and not rushed at meal times. Service users/representatives said staff, were lovely but they were so short staffed and so busy, they also commented that the standards of care had improved in the home over the last two weeks. Soft diets were served in an appetising way and there was a good supply of fresh vegetables and fruit. Service users said the food was lovely and confirmed they had choices. Catering staff were short on numbers and this had affected tea menus, of which sandwiches were prepared early in the day for care staff to serve later. Service users and staff confirmed that drinks were provided regularly and a water dispenser provided in the lounge areas. Avalon Care Home DS0000024627.V352841.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users and their relatives are hesitant to make complaints and a number of safeguarding adults investigations indicate that service users may not be fully protected from harm. EVIDENCE: The complaints procedure was displayed in the entrance area, however all those spoken with, were not familiar with the procedure and service users/representatives said they did not like to complain as staff were very good and they would not wish to get anyone into trouble. There were concerns expressed however about call alarms not being answered very quickly and having to wait to be assisted to go to the toilet. There were also comments made that the registered manager had not taken action when concerns had been raised in the past. However comments were also made that the management of the home has greatly improved in recent weeks. Avalon Care Home DS0000024627.V352841.R01.S.doc Version 5.2 Page 17 There were four complaints documented in the complaints records since the previous inspection, these were included reference to poor staffing levels, lack of personal hygiene needs being met, staff conduct, service users having to wait to be assisted to the toilet because of lack of working equipment. Three safeguarding adults investigations are currently being undertaken by, ‘Adult Social Care and Health’. Southern Cross has taken interim action in respect of these. The home had not however informed CSCI about these. 61 of staff has undertaken training in safeguarding adults in the last twelve months and 94 in manual handling, 88 in challenging behaviour and 94 in customer care. Some staff spoken with were not able to explain what the whistle blowing policy was about despite undertaking recent safeguarding training. One person said they would report abusive practices should they be aware of any Staff, were also not aware of the General Social Care Councils Code of Conduct. Two male staff were observed to potentially place themselves in a vulnerable situation despite evidence of being given previous guidance in this practice. The policies and practices regarding service users money and financial affairs were not inspected at this inspection due to time constraints. There was one incident reported to CSCI [Commission for Social Care Inspection] in respect of an incident between two service users that had not been referred under Safeguarding Protocols. The temporary manager agreed to refer this retrospectively. There had been a medication incident reported to the CSCI, [Commission for Social Care Inspection] but the outcome had not been forwarded. The temporary manager confirmed that the matter had been fully investigated and that spillage/wastage if the medication had been confirmed. A report is to be sent to CSCI Avalon Care Home DS0000024627.V352841.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22, 24 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users live in a clean, safe, well maintained environment, however the lack of keys to service users own bedrooms and lockable facilities provision does not promote their rights and privacy. EVIDENCE: The home is clean, hygenic and well maintained. There was some redecoration underway on the day of the inspection. Service users had a range of equipment to enable them to be as independent as possible, but they made comment that they had in the past had to wait sometimes for call alarms to be answered by staff. Avalon Care Home DS0000024627.V352841.R01.S.doc Version 5.2 Page 19 Records of checks on wheelchairs, lifts, hoists, bedrails were seen and found to be satisfactory. All manual handling tasks observed on the day of the inspection were satisfcatory. All hot water is regulated to ensure residents are safe from scalding risks. Service users spoken with did not have keys to their bedroom doors or lockable facilities, should they wish to have privacy of place and property. The rooms viewed were personalised and safe. There were no concerns raised about the heating and all servicing and maintenance records were satisfactory. Staff were observed to wear personal protective clothing as appropriate for the tasks they undertook. The kitchen was in need of a deep clean, particularly the exterior of fridges and freezers and there had been a lapse in some food safety record keeping, staff said, due to staff shortages and lack of time. The Provider was taking action to ensure the kitchen was cleaned to an acceptable standard and records were satisfactory on the day of the inspection. A fire risk assessment was in place. Avalon Care Home DS0000024627.V352841.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The numbers of staff provided currently meets Service users needs and recruitment practices are satisfactory. Staff receive training in health and safety topics, but further training covering the specific needs of service users is needed to improve the standard of care they receive and experience in the home. The maintenance of staffing levels need to be consistent, based on an assessment of service users’ needs and include evidence as to how they have been calculated to meet the health, safety and welfare needs of the service users. EVIDENCE: The rota was examined and on the day of the inspection and for 29 service users in residence, six care staff and one nurse was provided for the morning and five care staff and one nurse for the afternoon. For nights 3 care staff and one nurse were being provided. However during August and September the home had experienced a staffing crisis, which had clearly left service users and staff extremely vulnerable. Avalon Care Home DS0000024627.V352841.R01.S.doc Version 5.2 Page 21 Staff members confirmed statements by service user representatives and records that service users had not received a satisfactory standard of care, particularly around toileting and bathing, although one staff member was able to retrieve copies of bath records that had not been transferred to other records. Service user numbers were 36 during the previous two months. Examination of rotas for August and September showed that most morning shifts had been reduced to five carers and one nurse in a morning and 4 carers and one nurse in the afternoon and four days during this time were reduced to four care staff and one nurse in a morning and three care staff and one nurse in the afternoons, which is clearly not satisfactory particularly as staff reported that at least 27 service users required two staff to assist them with personal care needs. There had also been staffing shortages in the kitchen, with sometimes no catering staff cover after 2pm, which had compounded the care staff hours deficit and care staff having to undertake catering and laundry duties. Staff confirmed that the provider is taking action to deal with absenteeism and has a recruitment plan in place. Four staff personal files were examined and were found to contain the required documentation required by regulation, including induction and training records. There was evidence seen that some staff have achieved National Vocational Qualification training but exact numbers were not obtained at this inspection. There is a training plan for all staff that should provides them with the skills required to deliver the care to the residents at the home, however there is no training provided for equality and diversity and only 61 of staff have attended training in abuse awarenss in the last twelve months, 58 of staff have undertaken infection control and only 17 have attended training in care planning. 91 of staff have undertaken training in Dementia Care. There was limited evidence that staff have undertaken training in specific needs training such as epilepsy, diabetes, physical disability and other associated conditions. The provider must ensure that the staff conduct and practice issues raised during this inspection and any issues raised from the safeguarding adults investigations are addressed and suitable refresher training is provided for all staff, particularly around the rights, privacy, dignity and respect of service users and whistleblowing. Avalon Care Home DS0000024627.V352841.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although there were no health and safety issues noted at this inspection, the home has not been run in the best interests of service users, however it is acknowledged that action is being taken to improve outcomes for them. EVIDENCE: A temporary manager is currently in post, who is clearly addressing some problems recently experienced by the home, including poor record keeping, low staffing levels and poor care practices. Avalon Care Home DS0000024627.V352841.R01.S.doc Version 5.2 Page 23 There was minimal evidence of quality monitoring in the home. There was evidence of provider visits required by regulation 26 and of some audits, but only three completed surveys seen. One from a care professional and two from relatives, they were not dated however. One survey made reference to service users having to wait long periods for meals to be served, but were otherwise positive. There was no evidence of service user/representative meetings. Standard 35 was not assessed at this visit due to time constraints. Evidence was seen of staff supervision records, but some care staff had not received supervision of their practice, others had one session in six or twelve months only. No records were seen of staff meetings. There were six accident/incidents in respect of service users recorded in the homes records that had not been notified to CSCI. Three of these are currently being investigated as safeguarding cases. The provider must ensure that backdated notifications are made in respect of these to the commission. A sample of health and safety records was examined including the gas safety certificate and fire safety checks. The five yearly electrical certificate was not produced however. There were no issues identified otherwise in respect of health and safety. Avalon Care Home DS0000024627.V352841.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 2 2 2 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 1 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X 2 X 2 X 2 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X X 2 1 3 Avalon Care Home DS0000024627.V352841.R01.S.doc Version 5.2 Page 25 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 OP4 OP10 OP14 OP24 Regulation 12(4) Requirement You must take steps to make sure that service users are treated with dignity and respect by the staff. [This includes ensuring call alarms are answered promptly] 2 OP4 OP10 OP14 OP24 OP7 OP8 12[4] Ensure service users are 20/11/07 provided with keys to their bedroom door and lockable facilities unless their care plan states otherwise. Care plans must be developed in 20/11/07 consultation with service users so they are clear about how staff intend to help them. The care plans must provide clearer instructions to care staff on how the service is to be provided for each person to make sure the care provided is in line with the philosophy of care at the service. Ensure that arrangements are in 20/11/07 place for the recording, handling, safekeeping and administration and disposal of medicines received into the care home. DS0000024627.V352841.R01.S.doc Version 5.2 Page 26 Timescale for action 20/11/07 3 15 4 OP9 13 [5] Avalon Care Home [Ensure that the recommendations from the recent pharmacy audit are addressed as identified in the report.] 5 OP18 OP37 37 The registered person must give notice to the Commission without delay of the occurrence of the death of any service user, including the circumstances of death. The outbreak in the care home of any infectious disease, or any serious illness of a service user. Any event which adversely affects the well-being or safety of any service user, any theft, burglary or accident in the care home, any allegation of misconduct by the registered person or any person who works at the care home. Ensure the Commission for Social Care Inspection receive backdated notifications as identified. You must provide appropriate training for all members of staff on person centred approaches to working with service users and ensure that this is followed through in the care delivered to residents to make sure they are supported properly with their needs. You are required to carry out an assessment of service users’ needs and provide evidence to the Commission for Social Care Inspection as to how you calculate the appropriate staffing levels to meet the health, safety and welfare needs of the service users. 20/11/07 6 OP30 18(1)(a) & (c) 20/11/07 7 OP27 8(1)(a) 20/11/07 Avalon Care Home DS0000024627.V352841.R01.S.doc Version 5.2 Page 27 8 OP33 24 Also ensure sufficient catering staff are provided throughout the day. Further develop the quality 20/11/07 monitoring systems in the home to ensure service users and their representatives or visitors to the home are consulted about the service provided. 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 OP1 Good Practice Recommendations Ensure service users and their representatives are issued with their own copy of the Service User Guide and provided with information how they can access a copy of the inspection report including the web site address. The Service User Guide needs to include the range of fees charged also. Include how service users foot care will be managed in the assessment and care plan documentation. Ensure bowel records are consistently documented and followed up at handover for appropriate action. A more appropriate programme of activities should be developed to purposefully occupy residents, particularly those with Dementia who may not be able to do this alone. The staff must ascertain the wishes of residents and ensure that they uphold their choices, unless the care plan and risk assessment indicates that this is not appropriate. Consult with service users and their representatives about how they can be encouraged/supported to make complaints in an open culture. Ensure staff are fully aware of the whistle blowing policy and their responsibilities under the General Social Care Council Code of Conduct. Ensure evidence is provided that all staff have been issued with a copy of the code and whistle blowing policy. Ensure the kitchen deep clean is undertaken without DS0000024627.V352841.R01.S.doc Version 5.2 Page 28 2 3 4 5 OP3 OP8 OP8 OP12 OP14 6 7 OP16 OP18 8 OP30 Avalon Care Home 9 10 OP36 OP38 delay. Improve the frequency of staff supervision and introduce observation of practice/competency assessments as part of this system. Provide evidence of the five yearly electrical certificate to the Commission. Avalon Care Home DS0000024627.V352841.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Avalon Care Home DS0000024627.V352841.R01.S.doc Version 5.2 Page 30 - 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. 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