Inspection on 11/01/06 for Avalon Park Nursing Home

This inspection was carried out on 11th January 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 Park Nursing Home 22/01/07

Avalon Park Nursing Home 28/06/05

Avalon Park Nursing Home 25/01/05

Avalon Park Nursing Home 12/05/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Avalon Park Nursing Home Dove Street Oldham Lancashire OL4 5HB Lead Inspector Mrs Fiona Bryan Unannounced Inspection 11th January 2006 09:00 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 Park Nursing Home DS0000025426.V264892.R01.S.doc Version 5.0 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 Park Nursing Home DS0000025426.V264892.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Avalon Park Nursing Home Address Dove Street Oldham Lancashire OL4 5HB 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) 0161 633 5500 0161 633 8483 avalonpark@schealthcare.co.uk Southern Cross Healthcare Services Limited Mrs Denise Louise Simcock Care Home 60 Category(ies) of Dementia (30), Dementia - over 65 years of age registration, with number (30), Old age, not falling within any other of places category (11), Physical disability (28), Physical disability over 65 years of age (29), Sensory impairment (1), Sensory Impairment over 65 years of age (1) Avalon Park Nursing Home DS0000025426.V264892.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. 7. 8. 9. A first level registered general nurse to be in charge of the elderly physically infirm unit. Two registered general nurses to be on duty within the hours of 9 p.m. and 8 a.m. No resident may be admitted into the home who is less than 55 years old. Three registered general nurses to be on duty within the hours of 8 a.m. and 9 p.m. A first level registered mental health nurse to be in charge of the EMI unit. Number of persons accommodated - 60. Service user categories - OP, PD, PD(E), DE, DE(E), SI and SI(E). The home manager shall be a first level registered nurse and be supernumerary to the above stated. Service users to include 11 OP who require personal care only. Date of last inspection 28th June 2005 Brief Description of the Service: Avalon Park is a care home providing 24 hour nursing care for 30 older people and specialist dementia care for a further 30 people. The home can also provide for up to 11 people requiring personal care only, within these numbers. Avalon Park is owned and managed by Southern Cross Healthcare, which is a private limited company. It is managed on a day-to-day basis by a manager who is also a qualified nurse. The home is a purpose built, two-storey building and operates as two distinct units. Service users requiring general nursing care or personal care are accommodated on the ground floor. Service users requiring dementia care are accommodated on the first floor. The first floor accommodation is secure with access controlled by a keypad system. There are two lounges and two dining rooms on each Avalon Park Nursing Home DS0000025426.V264892.R01.S.doc Version 5.0 Page 5 floor. All bedrooms are single rooms with en-suite facilities. There is a passenger lift. Accessible toilets and bathrooms are located on both floors near to the lounges and dining rooms. The home is located in the Salem district of Oldham, on a main bus route, within a residential area and close to local shops. Avalon Park Nursing Home DS0000025426.V264892.R01.S.doc Version 5.0 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was undertaken by two inspectors who spent time talking to residents, visitors and staff. The needs of four residents were looked at in detail, with a particular focus being their experiences in the home from their admission to the present day. This was the second inspection of the year. At the last inspection in June 2005 the home was performing satisfactorily in many areas so the purpose of this inspection was to review progress in the areas that were identified as needing improvement. This was mainly related to how care plans were reviewed, the provision of social activities for residents, particularly those with dementia, staff training and the maintenance of the environment. Five other key standards, which have to be assessed at least once year were not examined at the last inspection, and were therefore considered at this inspection. These standards included how the home dealt with medicines, how the home managed residents’ personal finances and promoted residents’ choices and the qualifications of the manager and the care staff. A selection of documents was examined including residents’ care files, medicine records, and personal finance records, and staff training records. Standards which were not assessed at this inspection, were considered to be satisfactory at the last inspection. For further information about how the home met these standards please refer to the report of the inspection on 28th June 2005. What the service does well: The manager is approachable and accessible to staff, residents and relatives. One relative said the manager was “wonderful – she deserves a medal” and said the manager knew all the residents and relatives very well. One visitor said the home was “brilliant” and they were “100 happy with the service”. When asked what the best thing was about the home one resident said “everything is done for you”. Avalon Park Nursing Home DS0000025426.V264892.R01.S.doc Version 5.0 Page 7 What has improved since the last inspection? What they could do better: Although all residents were assessed before they entered the home, full details were not always obtained and in some cases identified needs had not been addressed in the resident’s care plan. This could lead to some aspect of care being overlooked or not delivered properly. Staff need to evaluate care and treatment more thoroughly and record their findings in more detail. The majority of staff were up to date with training in some mandatory health and safety topics such as fire safety and moving and handling, however other topics such as infection control and first aid had not been arranged for some time. In addition to this staff still require training in dealing with challenging behaviour and dementia care, and although some dementia care training has been planned for early this year the content seems limited to basic information and may not be comprehensive enough for staff working in a home whose statement of purpose is to deliver specialist care for people with dementia. It was also of concern that staff who have responsibility to deliver various training to other staff within the home do not have allocated time in which to plan training and carry it out. If staff are trying to “fit in” this additional commitment within their normal working day there is a high risk that other demands take precedence and time for training is compromised. Very few improvements were noted regarding the environment in which residents live. Under investment in the fixtures, fittings and décor of the home lead to many areas appearing neglected and shabby. A malodour was detected in some parts of the home, as the carpets need replacing. Bathrooms are not homely and were grimy and dreary. Although some work has been done regarding the provision of activities, this needs to be extended. More use could be made of information obtained during the assessment process to develop more person centred activities for individuals with specific interests. Staff could spend more time talking with residents especially when they are assisting them with daily living activities such as eating their meals. Avalon Park Nursing Home DS0000025426.V264892.R01.S.doc Version 5.0 Page 8 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 Park Nursing Home DS0000025426.V264892.R01.S.doc Version 5.0 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 Park Nursing Home DS0000025426.V264892.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 4 Although all residents are assessed before entering the home their needs are not always fully documented and care plans are not always implemented to meet assessed needs; therefore residents can not be certain that the home can meet their needs. Staff require further training to ensure that they are able to deliver care in a way that meets residents’ needs. EVIDENCE: Examination of four care files indicated that assessments had been undertaken of all residents prior to their admission to the home. Care management plans from Social Services were also on file. However, some details were missing from some assessments such as information about individual’s mobility or hygiene needs. Also, in some instances care plans had not been implemented although instructions to staff on Southern Cross’s own risk assessment documentation indicated that a care plan was required as the score obtained suggested a significant level of risk. There was no mental health assessment for one resident who had dementia. Avalon Park Nursing Home DS0000025426.V264892.R01.S.doc Version 5.0 Page 11 The manager stated that she would be delivering dementia care training over the first three months of 2006, but this will only consist of three one- hour sessions providing an overview of dementia care. This type of training is not sufficient for an establishment whose stated purpose is to provide specialist dementia care. It was noted that one carer engaged in minimal conversation with residents and he had some difficulty understanding questions put to him by the inspector as English was not his first language. Avalon Park Nursing Home DS0000025426.V264892.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Shortfalls in care planning and evaluation put residents at risk that their needs will not be met. Staff adhere to medicine management procedures thereby ensuring that the safety of residents is maintained. Residents are treated kindly and their privacy is upheld but better interaction between staff and residents would enhance their dignity and self-esteem. EVIDENCE: Examination of a selection of care files indicated that care plans for residents’ physical and personal care needs were generally detailed. However, no progress had been made regarding the social care plans for residents, which were not as specific as those for physical care needs. The main intervention suggested in these care plans was to refer the resident to the activities organiser but there was little detail about the types of leisure pursuits each resident enjoyed. Avalon Park Nursing Home DS0000025426.V264892.R01.S.doc Version 5.0 Page 13 Relevant information from the assessment of the resident was not always available on the care plan, for example one resident required a low fat diet due to a medical condition but no reference was made to this in the care plan. Risk assessment’s for moving and handling, falls, nutrition and pressure sores had been undertaken, although as stated previously a moderate to high score did not always trigger the implementation of an appropriate care plan. Evidence was available that advice from other health care professionals such as the dietician and the tissue viability nurse had been sought. Care plans for pressure care were detailed with information about the type of pressure relieving mattress in situ and the required pump setting. This is an example of good practice as it ensures staff have the information to check that the mattress is working effectively. Evaluations continue to be quite limited, as identified at the last inspection, for example the original care plan for one resident with challenging behaviour was quite generic and suggested recognising causes which made the resident agitated. The following evaluation of that care plan stated, “continue care as plan” without attempting to describe triggers for the residents behaviour. One resident had recently attended the hospital and was fully aware of her medical condition. This resident said that various treatment options had been discussed with her and she had been able to make an informed decision about her future care. One relative said that the resident she visited was always well presented, in clean and tidy clothing. Residents were noted for the most part to be reasonable well presented although several gentlemen needed shaving and another resident was shuffling rather than walking, as his shoes were not put on properly. Examination of a number of medicine records indicated that policies and procedures within the home were being adhered to. Residents are identified prior to medication administration by the use of photographs attached to the medication administration records. Staff members with responsibility for medication administration can be identified by the means of a staff signature sheet. Handwritten additions to medicine administration records were countersigned by two nurses. A record was maintained of medicines received and disposed of by the home. Controlled drugs were stored, administered and recorded satisfactorily. Avalon Park Nursing Home DS0000025426.V264892.R01.S.doc Version 5.0 Page 14 Staff were observed to interact with residents very differently. One carer was very good, explaining what she was doing and why. However another carer fed a resident without engaging in any conversation or explaining what the meal was and got up and walked away without saying goodbye. Another carer served drinks with no communication. Other staff were observed to offer drinks discreetly to residents although no conversation or words of encouragement were noted. However, residents and visitors said that staff were very pleasant and helpful. Avalon Park Nursing Home DS0000025426.V264892.R01.S.doc Version 5.0 Page 15 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 and 14 Further consultation is needed to ensure that the home satisfies all of the residents’ social and recreational needs. Residents who are able have some degree of choice regarding basic areas of everyday living. EVIDENCE: Since the last inspection the activities organiser has attended training provided by Age Concern regarding activities for people with dementia. Mixed views were offered about the provision of activities within the home. Care staff stated that they felt this was an area that had improved over recent months and that they tried to get involved and encourage the participation of residents. A memory room has been created which contained furniture and memorabilia from the early 20th century. It was reported that the activities organiser takes small groups of residents to the memory room for afternoon tea and reminiscence. A minister from the local church attends every fourth week and gives communion. Pupils from a local secondary school recently came to chat with Avalon Park Nursing Home DS0000025426.V264892.R01.S.doc Version 5.0 Page 16 residents as research for a drama they were producing about teenage life through the ages. Residents have been invited to attend the production. Some residents go out to a lunch club and went out on the day of the inspection. During the inspection some residents on the first floor participated in a game of darts, which they appeared to enjoy. A ball was also used to play catching games with some residents and others had a manicure. It was stated that other activities included card games, dominoes and time spent with individual residents undertaking specific activities with them. However, one resident spoke of “endless monotony” and said life at the home was boring and there was nothing to do. This resident said he had been a very good chess player. This information was in his care file but no efforts had been made to arrange a game for him. No record was made of any social activity that the resident had participated in other than being visited by his family. Care files in general contained sparse information about how the residents spent their time. One resident said she would prefer to be doing something and that everyone “just sits”. Another resident who preferred to spend most of the time in their own room was very content, spending time reading and watching the news and light entertainment shows on television. This resident said she was able to choose what time she got up and went to bed and how she organised the routine of her day. Avalon Park Nursing Home DS0000025426.V264892.R01.S.doc Version 5.0 Page 17 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): 18 Staff require further training in dementia care and challenging behaviour to ensure they are equipped with the skills and knowledge to protect the residents from abuse. EVIDENCE: The nurse in charge on the ground floor was aware of local adult protection procedures. Staff that have undertaken NVQ training have covered prevention of abuse as part of that course and it was reported by the manager that other staff had received some training in this topic in September 2005. Staff still require training in dealing with challenging behaviour. As stated elsewhere in this report mental health assessments had not been undertaken for all residents with dementia and the care plan for one resident with challenging behaviour did not give specific information to direct and advise staff in the most effective means to deal with this. Avalon Park Nursing Home DS0000025426.V264892.R01.S.doc Version 5.0 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, 20, 21, 24 and 26 There have been minimal changes to the décor and furnishings in the last twelve months and although this does not present a risk to residents it does not create a pleasing and pleasant environment to live in. Some parts of the home are malodorous causing a disagreeable environment. EVIDENCE: A maintenance person is employed for forty hours per week who undertakes health and safety checks of the building and equipment. Work had commenced on painting all the residents’ bedroom doors in individual colours to help those with dementia identify their rooms. Few of the environmental requirements made at the last inspection have been complied with. Woodwork and paintwork in most areas were showing signs of advanced wear and tear. Avalon Park Nursing Home DS0000025426.V264892.R01.S.doc Version 5.0 Page 19 The first floor was malodorous and the hallway and communal room carpets must be replaced. In addition to this the dining room carpet on the ground floor must be replaced, as it smelled badly of sour milk despite many attempts by staff to clean it. A strong malodour was noted in one bedroom on the first floor although the manager stated that the carpet was cleaned daily. Consideration must be given to other solutions to ensure that resident has a clean and pleasant environment to live and sleep in. Bathrooms appeared cold and clinical and were also dated and showing signs of wear and tear. Bathroom floors identified during the inspection need replacing. The grouting between tiles and around sinks was grimy and unpleasant. A shower that was planned and agreed by the head office for January 2005 has still not been installed. Much of the bedroom furniture was old and many carpets showed signs of wear and tear. Many of the armchairs in the communal rooms were dated and table legs and chair legs were sticky and dirty. Keypad locks on each of the floors ensure that residents are safe to move independently if able, around the units. Avalon Park Nursing Home DS0000025426.V264892.R01.S.doc Version 5.0 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): 28 and 30 The percentage of care staff working at the home who have completed NVQ training does not meet the required targets. Further training is required to ensure that all staff have the skills and knowledge to deliver care to the residents competently. EVIDENCE: Nine care staff have completed NVQ’s and a further two staff were overseas nurses who are working as carers in this country. As there are 32 carers in total in employment, the target of 50 of care staff having achieved this qualification has not been met. Staff said they had received mandatory training in moving and handling, fire safety and food hygiene since the last inspection. Further training is needed in dealing with challenging behaviour and dementia care – some staff had undertaken this training but not recently. Neither the manager nor any other member of staff is allocated designated time to deliver staff training but is expected to “fit it in” around their other commitments, for example one of the nurses is the home’s moving and handling facilitator and is responsible for delivering this training and updates to all staff but has no scheduled time away from his duties as nurse in charge to do this. In a home of this size with the numbers of staff involved this is impracticable and does not allow for training to be delivered consistently. Avalon Park Nursing Home DS0000025426.V264892.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 35 and 38 The manager has the skills and knowledge to properly manage the home. Residents’ financial interests are safeguarded. Further staff training is needed to ensure that the health, safety and welfare of residents and staff are protected. EVIDENCE: The manager has nearly completed the registered managers award and attends all mandatory training in respect of health and safety. The manager also maintains continuous professional development through resources such as the internet and professional magazines. Staff reported that the manager was very approachable and that regular staff meetings were held. A qualified staff meeting was actually arranged for the Avalon Park Nursing Home DS0000025426.V264892.R01.S.doc Version 5.0 Page 22 afternoon of the day of inspection. Minutes for the last staff meeting on 16/12/05 were available. One visitor was very complimentary regarding the manager stating that she was always available to provide assistance and support The majority of residents are assisted with their finances by their families. A small number of residents receive their personal allowance by cheque from Oldham Social Services. This money is paid into a bank account set up specifically for the purpose of administering residents’ monies. Separate ledger sheets are maintained for each resident detailing how much money they have in this bank account. The bank account does not attract interest, therefore when an individual accrues a significant amount of money in this account a separate account will be opened for that resident so they can receive interest on the balance. Records and receipts are maintained of all transactions made on behalf of the residents. Comprehensive records were available of fire alarm tests, drills and training. Records were maintained of weekly and monthly checks on the building and equipment and service reports were available. Two staff said they had received training in fire safety, food hygiene and moving and handling since last inspection. Staff were observed using the hoist but had some difficulty and appeared to be using a sling that was not suitable for the purpose. Staff had not received any recent training in infection control or first aid and there are no designated first aiders in the home. Avalon Park Nursing Home DS0000025426.V264892.R01.S.doc Version 5.0 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 2 2 2 X X 2 X 2 STAFFING Standard No Score 27 X 28 2 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 3 X X 2 Avalon Park Nursing Home DS0000025426.V264892.R01.S.doc Version 5.0 Page 24 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP3 Regulation 14 Requirement The registered person must ensure that pre-admission assessments include all the details stated in Standard 3.3 of the National Minimum Standards. The registered person must ensure that where assessment indicates a significant level of risk to a resident, a plan of care is implemented to reduce or eliminate the risk. The registered person must ensure that staff receive dementia care training to a level that is suitable to equip them with the skills and knowledge to deliver specialist care. The registered person must also ensure that staff receive training in dealing with challenging behaviour and other training specific to the care they are expected to deliver. (Timescale of 31/12/05 not met). The registered person must ensure that residents care plans set out in detail the action which needs to be taken to ensure that DS0000025426.V264892.R01.S.doc Timescale for action 28/02/06 2 OP3OP7 13, 15 28/02/06 3 OP4OP18O P30 18 30/06/06 4 OP7OP8 15 28/02/06 Avalon Park Nursing Home Version 5.0 Page 25 5 OP7 15 6 OP10 12 7 OP12 16 8 OP19 23 9 OP21 23 10 OP21 23 11 OP28 18 12 OP38 13, 16 all aspects of the health, personal and social care needs of the residents are met. The registered person must ensure that care plans are evaluated thoroughly and updated to reflect the changing needs of the residents. (Timescale of 31/08/05 not met). The registered person must ensure that staff interact appropriately with residents and in a way that is respectful and takes into account their wishes and feelings. The registered person must ensure that residents are consulted with about their social interests and arrangements are made for activities, which take into account the needs of the residents. The registered person must ensure that carpets identified in the inspection are replaced. (Timescale of 30/11/05 not met). The registered person must ensure that the bathroom floors identified during the inspection are replaced. (Timescale of 30/11/05 not met). The registered person must ensure that the shower agreed for installation in January 2005 is fitted. The registered person must ensure that care staff are supported to undertake NVQ training to ensure that the target ratio is achieved. The registered person must ensure that staff receive training in infection control procedures and first aid and must further ensure that there is a qualified first aider identified amongst the DS0000025426.V264892.R01.S.doc 28/02/06 28/02/06 31/03/06 30/04/06 30/04/06 31/03/06 30/09/06 30/06/06 Avalon Park Nursing Home Version 5.0 Page 26 staff. 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 OP20OP24 OP21 OP26 OP30 OP38 Good Practice Recommendations The registered person should replace old and worn furniture in bedrooms and communal rooms and ensure that furniture is kept clean. The registered person should refurbish the bathrooms. The registered person should ensure that other measures are taken to diminish the malodour in the resident’s room identified during the inspection. The registered person should ensure that staff responsible for the delivery of training are allocated designated time in which to undertake this work. The registered person should ensure that staff are confident in the use of the hoist. Avalon Park Nursing Home DS0000025426.V264892.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection Ashton-under-Lyne Area Office 2nd Floor, Heritage Wharf Portland Place Ashton-u-Lyne Lancs OL7 0QD 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. Extracts may not be used or reproduced without the express permission of CSCI Avalon Park Nursing Home DS0000025426.V264892.R01.S.doc Version 5.0 Page 28 - 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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