Inspection on 22/01/07 for Avalon Park Nursing Home

This inspection was carried out on 22nd January 2007.

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

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

Other inspections for this house

Avalon Park Nursing Home 11/01/06

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 22nd January 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Avalon Park Nursing Home DS0000025426.V329266.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 Park Nursing Home DS0000025426.V329266.R01.S.doc Version 5.2 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 www.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.V329266.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. 7. 8. 9. Number of persons accommodated - 60. Service user categories - OP, PD, PD(E), DE, DE(E), SI and SI(E). 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. Two registered general nurses to be on duty within the hours of 9 p.m. and 8 a.m. A first level registered mental health nurse to be in charge of the EMI unit. A first level registered general nurse to be in charge of the elderly physically infirm unit. 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 11th January 2006 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. Avalon Park is owned and managed by Southern Cross Healthcare. 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 of the home. The first floor accommodation is secure with access controlled by a keypad system. There are two lounges and two dining rooms on each 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. Avalon Park Nursing Home DS0000025426.V329266.R01.S.doc Version 5.2 Page 5 The home is located in the Salem district of Oldham, on a main bus route, within a residential area and close to local shops. Fees for accommodation and care at the home range from £315 to £587 per week. Additional charges are also made for hairdressing, chiropody, newspapers and personal toiletries. A service user guide is normally on display in the reception area of the home and a copy is provided in all residents’ rooms. The service user guide is being amended at the moment. Avalon Park Nursing Home DS0000025426.V329266.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection, which included a site visit, took place on Monday 22nd January 2007. Time was spent talking to residents and staff and observing the home’s routine and staff interaction with residents. Four residents were looked at in detail, looking at their experience of the home from their admission to the present day. A partial tour of the building was conducted and a selection of staff and residents’ records was examined including records of care, medication records, employment and training records and staff duty rotas. What the service does well: What has improved since the last inspection? Since the last inspection improvements have been made in how staff assess and record what care each resident needs. This makes it easier for everyone to know what care they need to provide and means residents’ needs are more likely to be met. Training has started to make sure that all staff know how to recognise and report any concerns about residents’ safety or potential abuse. Training in Avalon Park Nursing Home DS0000025426.V329266.R01.S.doc Version 5.2 Page 7 general has improved with more staff undertaking training in dementia care and other topics such as first aid. Improvements have been made in how the laundry operates and this was very noticeable, as many of the residents appeared much neater and tidier as their clothing had been properly ironed. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Avalon Park Nursing Home DS0000025426.V329266.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 Park Nursing Home DS0000025426.V329266.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. Residents are assessed before they come into the home so staff have the information to meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Four residents were case tracked. Pre-admission assessments had been undertaken for all the residents. Specialist assessments had also been undertaken where necessary. Attempts had been made to create a social profile for each resident, providing information about their family, previous career and hobbies, interests and preferences. Avalon Park Nursing Home DS0000025426.V329266.R01.S.doc Version 5.2 Page 10 Some social profiles were more informative than others depending on the degree of input from the residents’ families, as it was difficult for staff to obtain a lot of information from the resident themselves. Staff said that the acting manager went to see prospective new residents before they came into the home and they were told about the residents’ care needs and preferences on their admission. Staff were knowledgeable about the residents’ needs and were able to describe their likes and dislikes. Residents felt that staff understood their needs. One resident said “(staff) know my routine”. Intermediate care is not provided at Avalon Park. Avalon Park Nursing Home DS0000025426.V329266.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. Care plans and risk assessments were generally successful in identifying residents’ physical, social and health care needs. Physical and health care needs were usually met well. Systems for the administration of medicines were mainly satisfactory and ensured the safety of residents. Residents and their representatives felt they were treated with respect. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Four residents were case tracked. All had care plans that generally identified and addressed their needs. Care plans were quite person-centred and had been reviewed regularly. Reviews could have been more detailed though, as Avalon Park Nursing Home DS0000025426.V329266.R01.S.doc Version 5.2 Page 12 they often only said that the care plan had been reviewed and was still valid, without offering any further evaluation of the effectiveness of the planned care. Some residents displayed challenging behaviour on occasion. Care plans had been written and records kept where staff had tried to identify possible triggers that had caused the behaviour and suitable techniques that diffused the situation. Although care plans had been written to address residents’ social care needs more thought needs to be given as to how those needs can be met in practice. This issue is discussed in more detail in the following section of this report. Risk assessments had been undertaken for pressure areas, falls, nutrition and moving and handling. In one case if the dietician had not been contacted although the risk assessment indicated that this was needed as the resident had lost weight. However, residents said that their GP was contacted if they were ill and records confirmed that health care services had in the main been accessed for residents when needed. Eight residents returned comments cards. Of these 6 said they always received the care and support they needed, whilst 2 said they usually did. All said that staff listened and acted on what they said and that they received the medical support they needed. Records were maintained to show where the residents’ representatives had been contacted. These showed that relatives had been kept informed about changes to the residents’ health. One resident was aware that she had a care plan as staff had discussed it with her. The records and medicines for the residents that were case tracked were checked and satisfactory. A large quantity of insulin had accumulated for one resident dating back to September 2006. Nurses should check the stock of each item of medication before re-ordering to keep stocks to a minimum. Residents throughout the home appeared clean and tidy and were dressed appropriately. An improvement since the last inspection was noted in the maintenance of residents’ clothing, which had been ironed properly and looked much better as a result. All the residents spoken to said that staff were pleasant and caring, and treated them with respect. One resident said “staff are very pleasant to you. They all give you the time of day and say good morning to you”. Another Avalon Park Nursing Home DS0000025426.V329266.R01.S.doc Version 5.2 Page 13 resident said “The carers are very civil and helpful” and another said “the staff are very nice – if you ask them to do anything they do it straight away”. Staff were observed to be interacting with residents appropriately in attitude and manner. Avalon Park Nursing Home DS0000025426.V329266.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. Activities arranged provide for some stimulation and enjoyment, although more consideration should be given as to how residents’ more diverse needs are recognised and acted upon. Visitors are encouraged and welcomed into the home to enable residents to maintain family contacts. The home offers a reasonably well-balanced and varied selection of food that meets the majority of residents’ tastes and choices. . This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home employs a full time activities organiser (who was not present during the inspection) but residents were quite vague about the type of social events and leisure pursuits that were available to them. One resident said there were sing-a-longs. Staff said residents enjoyed bingo and several residents Avalon Park Nursing Home DS0000025426.V329266.R01.S.doc Version 5.2 Page 15 went out for lunch on the day of the site visit. One resident said a staff member came and painted her nails for her from time to time. Minimal information was available in residents’ records about how they had spent their day or how their social care needs had been met. Some residents had individual interests but staff did not always promote them as fully as they might. For example one resident said she used to enjoy knitting but was no longer able to do this. However, other handicrafts that she might have been able to do had not been explored. Also the needs of one resident whose first language was not English could easily have been better met by considering the knowledge and skills of the staff employed and changing the key worker assigned to the resident. Care plans should also contain information for staff about significant needs related to residents’ culture and traditions where appropriate. Many of the residents spent a lot of time sitting in the lounge and seemed quite content, although one resident said she “sometimes got a bit bored”. The television was on in several lounges but no one appeared to be watching. Residents said one of the televisions was not working but “staff are going to have a look at it”. The manager said that Southern Cross Healthcare was, as a company looking at the provision of activities in all its homes and recognised that this was an area for development. Residents said their visitors were made welcome. One resident who was blind had a large push button telephone so that she was able to phone friends and family more easily. Evidence from the daily reports showed that residents’ routines were fairly flexible. One resident said “I go to bed at my choice”. However, some residents’ diverse needs were not always managed very well. For example the care plan for one resident who was registered blind said they liked to listen to the afternoon play on radio 4 but the resident said she had stopped listening to it as she was often interrupted by staff coming to attend to her personal hygiene. The manager was in agreement that staff should be able to work round specific needs such as these. The home offers a three-week menu. The majority of residents were satisfied with the food provided. One resident said, “It is my kind of food they put on”. Another resident said, “The food is good – we get nice sandwiches. The beef burgers and sausages are good and the pasties. We had a lovely Christmas dinner – turkey and all the trimmings and a glass of sherry”. One resident said the food was not good, saying that there was a choice but it tended to be the same things and the overall menu was lacking in variety. Avalon Park Nursing Home DS0000025426.V329266.R01.S.doc Version 5.2 Page 16 Residents all agreed that there was a choice at breakfast time and that they could have a cooked breakfast if they wanted one. Of 8 residents who returned comments cards, 2 said they always liked the meals, whilst 5 said they usually did. One relative said when she visited the menu was good and varied. Lunch on the day of the site visit was fish fingers and chips or sandwiches, followed by sponge and custard or fresh fruit. The menu for tea was liver and onion or meat pie, vegetables, fruit and cream or ice-cream. Examination of the menus showed that a hot meal was on offer at both lunch and tea time every day. Although arrangements were made at the weekends for halal meals to be prepared for some residents, the choice during the week was more limited. This was discussed with the manager who felt that other arrangements could be made to offer the residents more choice. Avalon Park Nursing Home DS0000025426.V329266.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. Residents feel that their views are listened to and acted upon. Arrangements for protecting residents from abuse are satisfactory. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaints procedure, which is displayed in the reception area. Staff and residents said they would bring any concerns or complaints to the attention of the acting manager and all felt confident that she would address any issues appropriately. All 8 residents who returned comments cards said they knew how to make a complaint and who to speak to if they were not happy. The complaints record showed that since the last inspection one complaint had been made and this had been dealt with satisfactorily. An ongoing programme is in place so that staff receive training in topics such as safe guarding adults, challenging behaviour and dementia care. Bruising or injuries to the residents are recorded on “body maps” and kept in the resident’s care file. This ensures that the frequency of such injuries can be Avalon Park Nursing Home DS0000025426.V329266.R01.S.doc Version 5.2 Page 18 monitored and risk assessments reviewed to minimise further risk, and that unexplained bruising is taken seriously and the cause identified. Avalon Park Nursing Home DS0000025426.V329266.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21 and 26 Quality in this outcome area is adequate. Despite some improvements to the décor further investment needs to be made to ensure that residents live in a comfortable and safe environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has made some progress in undertaking refurbishment and has provided fifteen new carpets, ten new chairs and purchased ten complete sets of bedroom furniture. This progress needs to continue in order to provide a good standard of accommodation for residents. It was reported that the home was due for a full scale refurbishment in the near future. Avalon Park Nursing Home DS0000025426.V329266.R01.S.doc Version 5.2 Page 20 A requirement made at the last inspection to fit a shower has still not been met and staff said that on the first floor there was only one fully operational bathroom as the bath hoists in 2 bathrooms are broken. A selection of rooms was inspected. Many residents had personalised their rooms with items brought in from home e.g. chairs and hi-fi equipment. One resident said, “My room is very comfortable”. Some nurse call bells were inaccessible to residents. This was discussed with the manager who reported that in these cases residents were unable to access the call bell because of physical disabilities or mental health problems and regular checks were made by staff to ensure their safety. The home provides secure garden areas, which, are well maintained and provide seating for residents. One resident said, “ It is very good to sit out in nice weather and we can get out because it is a flat surface. “ The laundry had been provided with new equipment to ensure residents’ clothes were washed and ironed at appropriate temperatures. The home was clean and tidy although a musty smell was noted on the first floor, as the carpets have still not been replaced. Eight service users’ comments cards were returned to the inspector, six of which said the home was always fresh and clean and two said it was usually clean and tidy. Avalon Park Nursing Home DS0000025426.V329266.R01.S.doc Version 5.2 Page 21 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 and 30 Quality in this outcome area is adequate. There are adequate staffing levels to meet the needs of the residents. Staff training has increased in the home ensuring residents’ health care needs are met. The procedures for the recruitment of staff are not robust enough to ensure protection for residents. EVIDENCE: The home had a relaxed peaceful atmosphere. Staff did not rush and good interactions with staff and residents were observed. On the day of the site visit enough staff were on duty to meet the needs of the residents and examination of staff duty rotas showed that these staffing levels were the norm. Of 8 residents who returned comments cards, 4 said there were always enough staff available and 4 said there usually were. Avalon Park Nursing Home DS0000025426.V329266.R01.S.doc Version 5.2 Page 22 Examination of the home’s recruitment procedures found some shortfalls in recording and storing of information. Four files were examined, one reference had not been fully explored, and in another a reference had not been sent for from the previous employer. No explanation for this was recorded. The manager reported that CRB and POVA first information was kept at the company’s head office, with a copy being sent to the home. In one file, although a CRB was available it had been issued after the date the employee had started work and there was no record of a POVA first check being done. This information must be kept on the employee’s file. Staff training had increased since the last inspection. Ten staff had been trained in first aid and all were appointed first aiders. Other training included moving and handling, infection control, dementia care, and managing challenging behaviour. In addition to this over 50 of staff had achieved NVQ2. A record of all staff training was maintained. During interviews staff confirmed that they received an initial induction to the home and the needs of residents. This was then followed up with a more in depth induction in line with Skills for Care. Avalon Park Nursing Home DS0000025426.V329266.R01.S.doc Version 5.2 Page 23 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 and 38 Quality in this outcome area is good. Appropriate leadership, guidance and direction to staff ensure the safety and welfare of residents. Consultation processes ensure that the home is run in the best interests of the residents. Procedures for dealing with residents’ finances protect their interests. Health and safety policies and procedures protect residents. This judgement has been made using available evidence including a visit to this service. Avalon Park Nursing Home DS0000025426.V329266.R01.S.doc Version 5.2 Page 24 EVIDENCE: Since the last inspection the previous manager has retired .The deputy manager has been acting up in this position and receives support from the company’s operational manager. The company is actively recruiting to appoint someone for the post. There was documented evidence that regular meetings had taken place with relatives, residents and staff. Minutes of the staff meetings showed that maintaining documents and keeping records to the appropriate standard, training issues, and the importance of spending time talking to residents were the type of topics discussed. Staff confirmed at interview the topics of the meetings and how these had been put into practice. Residents said, “Staff talk to us and ask us what we want throughout the day”. Examination of residents’ finances found that there was no inappropriate expenditure recorded. At present residents’ monies are held in a pooled account. The acting manger reported discussions had taken place with a leading bank to hold residents’ finances in individual accounts with each receiving interest on monies held. The acting manager reported that a weekly audit takes place to ensure monies held on behalf of residents match records held. The home employs a dedicated maintenance employee who undertakes the required testing of equipment and monitoring of health and safety. Staff training in first aid and health and safety had improved since the last inspection. Staff were observed to be working using safe working practices. Avalon Park Nursing Home DS0000025426.V329266.R01.S.doc Version 5.2 Page 25 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 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 2 X 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 3 X 3 X X 3 Avalon Park Nursing Home DS0000025426.V329266.R01.S.doc Version 5.2 Page 26 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 OP29 Regulation 19 Requirement The registered person must ensure that all information and documents specified in Schedule 2 of the Care Homes Regulations 2001 are obtained in respect of new employees. (References must be obtained from the previous employer and written confirmation must be on file that CRB’s and where applicable POVA First checks have been obtained before employment commences). Timescale for action 15/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP7 Good Practice Recommendations The registered person should ensure that staff review care plans thoroughly and are more rigorous in recording the effectiveness of the care plan in place. Avalon Park Nursing Home DS0000025426.V329266.R01.S.doc Version 5.2 Page 27 2 OP12 The registered person should ensure that further consultation is made and consideration is given as to how residents’ diverse needs can be met. The registered person should ensure that the planned refurbishment programme is carried out. The registered person should ensure that there are sufficient numbers of usable bathrooms. 3 4 OP19 OP21 Avalon Park Nursing Home DS0000025426.V329266.R01.S.doc Version 5.2 Page 28 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: 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 Park Nursing Home DS0000025426.V329266.R01.S.doc Version 5.2 Page 29 - 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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