Inspection on 02/09/08 for Aveley Lodge

This inspection was carried out on 2nd September 2008.

CSCI found this care home to be providing an Adequate service.

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

Aveley Lodge 03/03/08

Aveley Lodge 03/09/07

Aveley Lodge 23/04/07

Aveley Lodge 18/12/06

Aveley Lodge 19/05/06

Aveley Lodge 13/01/06

Aveley Lodge 18/03/05

Aveley Lodge 28/07/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 26/11/2008.

CARE HOMES FOR OLDER PEOPLE Aveley Lodge Abberton Road Fingringhoe Colchester Essex CO5 7AS Lead Inspector Neal Cranmer Unannounced Inspection 2nd September 2008 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 Aveley Lodge DS0000017757.V371036.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. Aveley Lodge DS0000017757.V371036.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Aveley Lodge Address Abberton Road Fingringhoe Colchester Essex CO5 7AS 01206 729304 F/P 01206 729304 michaelparmenter@doctors.org.uk 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) Mr Robin Parmenter Mr Michael Ian Parmenter Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21) of places Aveley Lodge DS0000017757.V371036.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may accommodate 21 persons of either sex who only fall within the category of Old Age 3rd March 2008 Date of last inspection Brief Description of the Service: The home is situated in the village of Fingringhoe, Essex, and benefits from being within reasonable bus/car ride of a range of local amenities provided by the historical town of Colchester. Aveley Lodge offers a number of single rooms, some of which have en-suite facilities. The home has two lounges and a conservatory area. Extensive grounds can be found to the rear of the property. The range of monthly fees supplied to the Commission for Social Care Inspection (CSCI) on the day of the inspection is £420.00 to £520.00 per week, with an additional charge being made for hairdressing and chiropody. This information was provided verbally to the inspector at the time of the inspection. Aveley Lodge DS0000017757.V371036.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is one star. This means the people who use this service experience adequate quality outcomes. This report follows a key unannounced inspection of the home, which took place on the 2nd September 2008. This inspection included discussions with members of the management team, service users, members of the staff team, and a number of relatives, in addition interactions between staff and service users were observed An inspection of the premises, including the viewing of service users rooms, bathing and toilet facilities, as well as the home’s laundry was undertaken. An inspection of a sample of records was undertaken. Eight feedback questionnaires were received, five from relatives and three from staff. What the service does well: Comments received from relatives surveys were mixed and included: ‘Very nice staff’. ‘Good skill mix of staff’. ‘Meetings with management have not always been satisfactory, and leave a lot to be desired’. ‘Good food’. ‘I get the impression that staff always have an ‘I know best attitude to relatives’. ‘Homely and comfortable, with pleasant nice gardens’. ‘Hygiene in the kitchen needs to be addressed’. ‘There is a very apparent desire to please, and do their best’. ‘Communicates a caring family attitude where nothing is to much trouble’. Aveley Lodge DS0000017757.V371036.R01.S.doc Version 5.2 Page 6 ‘Tendency towards being intimidating towards relative’. Further information received via response from surveys is included within the relevant sections of this report. The home continues to provide care and support to people in an environment that is comfortable, homely and generally well maintained. Discussions with people living in the home and relatives both visiting the home, as well as responses received from relative’s surveys indicated that carers were caring and polite. The home manages money held on behalf of people living in the home well and there is a clear audit trail of expenses made. What has improved since the last inspection? What they could do better: A care plan must be developed for all service users residing in the home that adequately reflect all of the needs of the person. Provision must be made by the home to ensure that any complaints received are logged, investigated in accordance with the home’s complaints policy and responded to. The flooring in the home’s laundry room requires replacing, to ensure that it is of a surface that maybe easily kept clean. Aveley Lodge DS0000017757.V371036.R01.S.doc Version 5.2 Page 7 Provision needs to be made to ensure that evidence can be provided to confirm that staff are Nationally Vocationally Qualified at level 2 or better. Provision must be made to ensure that all staff receive regular formal supervision. 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. Aveley Lodge DS0000017757.V371036.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 Aveley Lodge DS0000017757.V371036.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): 1, 3, Standard 6 could not be inspected on this occasion. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who may use the service are provided with the necessary information to enable them to make a choice about the home’s ability to meet their needs. People who may use the service can expect their needs to be assessed prior to a service being provided. EVIDENCE: The home’s Statement of Purpose and Service Users Guide were both seen, and there was evidence that they had been fully reviewed in May 2008, and scheduled to be reviewed again in May 2009. The Statement of Purpose clearly set out information regarding the names of staff along with their qualifications, the services provided, accommodation, amenities and the support that service users could expect to receive from the home. Also included were the terms and conditions of residency. The Service Users Guide included information on how to make a complaint. Both Aveley Lodge DS0000017757.V371036.R01.S.doc Version 5.2 Page 10 documents contained sufficient information to enable a prospective service user to make a decision on the home’s ability to meet their needs. The home has had three new admissions since the last inspection undertaken in March 2008. Each of the assessments sampled included details regarding the service users next of kin, date of admission, where they were admitted from, who they were referred by, their General practitioner and details of other agencies involved, information regarding their physical healthcare needs including personal care needs, diet and dietary preferences, any known allergies, their religion, and mental status, including orientation e.g. sense of time, what the service users mood state was and whether they presented as confused or anxious. Further information-included details regarding sight, method of communication, oral health, foot care, mobility and dexterity, any history of falls, and the service users weight upon admission. The level of detail in the assessment was sufficient to ensure that staff were clear about the needs and that they could be met. Information from these assessments was used as the basis for formulating the plans of care that were sampled. Aveley Lodge DS0000017757.V371036.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 adequate. This judgement has been made using available evidence including a visit to this service. The health and personal care that people receive is based on their individual needs, however not all needs for all people were laid out in an individual plan of care. EVIDENCE: Four service users plans of care were sampled as part of the inspection process, three of which were found to be comprehensively detailed, including evidence of a full needs assessment having been carried out. Care plans were based on the activities of daily living and those in place included plans on keeping service users well nourished and hydrated, and including service users to remain physically active. The guidance to staff as to how service users identified needs were to be met was clear and concise, with the care plans identifying the need and support required to meet the need. Daily records relating to care plans were seen. Each of the care plans had been reviewed on a monthly basis since their implementation in May of this year. Aveley Lodge DS0000017757.V371036.R01.S.doc Version 5.2 Page 12 The staff surveys returned varied with regards to how staff felt that they were provided with information about the needs of the people they supported, two responded that they were sometimes provided with information, while the third stated they were always provided with information. The fourth service user case tracked had a needs assessment in place, however there was not a care plan in place. Discussion with a member of the management team gave some reasons for this, however it must be pointed out that a plan of care must be put in place upon admission to ensure that staff are provided with guidance as to how the service user should be supported, and to ensure that their needs can be met. All service users are registered with a General Practitioner, and district nurses visit the home on a regular basis. Discussion with a district nurse on the day of the inspection was positive. The nurse spoke of staff being aware of service users needs, and being quick to contact them if they were required. Healthcare records sampled in care plans provided evidence of records being kept regarding food intake, and weight, further records were in place regarding healthcare appointments with dentists and district nurses. Other health assessments in place included pressure area care and nutritional screening. At the previous key inspection undertaken in March this year there were significant concerns expressed regarding the home’s practice in relation to the administration of service users medication. Since that time significant improvement has been made. A detailed policy has been put in place on the ‘Safe Handling of Medicines’ and the home has changed its dispensing pharmacy and now receives its medication in a Measured Dosage System (MDS) or in individually named containers. Medicines received in the home a stored in a locked metal cabinet, the temperature of which is checked daily and recorded. Only senior staff administer medication upon completion of training provided by the dispensing pharmacy. Medication keys are held at all times by the person in charge of the shift. Medication administration records sampled were found to be in order with no evidence of any gaps or omissions. The home does maintain controlled medication which are stored in a locked cupboard in the home’s office, records relating to these were in order, with the medication being recorded in a correct controlled medication register. Overall it was felt that the home’s medication practice afforded protection to service users. Observation of interactions between staff and service users indicated that people’s dignity and privacy is upheld, interactions witnessed were respectful and polite, and discussion with service users indicated that staff were very nice, helpful and polite. Aveley Lodge DS0000017757.V371036.R01.S.doc Version 5.2 Page 13 Staff were heard and observed referring to service users by their chosen forms of address. Discussion with the visiting district nurse indicated that all examinations of a physical nature are always undertaken the privacy of the service users bedroom. Aveley Lodge DS0000017757.V371036.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 good. This judgement has been made using available evidence including a visit to this service. People who use the service are able to make choices about their life style, and are supported to develop their life skills. Social, educational, cultural and recreational activities meet individual’s expectations. EVIDENCE: The home now employs an activities co-ordinator part-time. Sampling of care plans showed that activities assessments have now been undertaken, records further showed that activities are taking place on a daily basis including: gardening, 1.1 chats, playing draughts and chess and quizzes. Discussion with the deputy manager also indicated that they are in the process of developing life storybooks. On the day of the inspection service users were observed taking part in a game of floor snakes and ladders with members of the care team, observation of which indicated that service users were enjoying themselves, people were seen sitting forward looking interested. One service user spoken with spoke of the mobile library, which visits the home monthly, and of withdrawing novels. Aveley Lodge DS0000017757.V371036.R01.S.doc Version 5.2 Page 15 The home has an open door policy on the receiving of visitors to the home. Those spoken with on the day of the inspection spoke of generally being made welcome, particularly by care staff, although this was not the experience of all. Feedback from surveys indicated that relatives sometimes felt intimidated, feeling that the staff had an attitude of ‘We know best’. Discussion with service users indicated that they were free to bring personal possessions with them when moving into the home. Meals are provided three times daily, at least one of which is provided as a hot meal. Sampling of the home’s menu showed that service users are provided with a continental style breakfast and cooked lunch. Tea is usually sandwiches and cake, and drinks are available throughout the day. The lunchtime meal, which was discreetly observed on the day of the inspection visit, was seen to be taken in comfortable surroundings. Service users who required assistance to eat their meal were seen to be appropriately supported on a 1.1 basis. Discussion and feedback from three service users and one relative indicated that the food had improved, service users stated that it was good, and that they received enough. Aveley Lodge DS0000017757.V371036.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. People who use the service are able to express their concerns, and have access to a robust, effective complaints procedure, however not all complaints received are appropriately logged and investigated. People are protected from abuse, and have their rights protected. EVIDENCE: The home has a comprehensive complaints policy in place, which included information on how to register a complaint, how the complaint would be investigated, what would be the timescale within which the complaint would be responded to, and what the complainant may do if they remained dissatisfied with the outcome. Discussion with three service users and feedback received from relative’s surveys indicated that both service users and relatives were aware of how and with whom to raise any complaints. The Commission for Social Care Inspection (CSCI) had received a complaint since the last key inspection undertaken in March of this year. The complaint received has now been forwarded to the manager of the home for them to investigate under the home’s complaints process. Sampling of the home’s complaints log contained no reference to this complaint, so it was not possible to determine whether or not the complaint had been investigated and responded to under the home’s complaints policy and procedure. Aveley Lodge DS0000017757.V371036.R01.S.doc Version 5.2 Page 17 The home has in place a comprehensive policy on safeguarding, in two parts. The first was guidance for service users (copies of this guidance was seen in each of the care plan files sampled) and covered: What the home will try and do, how we will try and ensure your safety, what you should do if you think someone is abusing you, what you should do if you think someone is being abused, who abusers maybe, contact details of where you may get further assistance including CSCI. Part two related to staff and included: what is meant by the term vulnerable adult, what is meant by abuse, who maybe an abuser, in what circumstances may abuse occur, signs of possible abuse and what to do if you suspect abuse is occurring. All of the staff files sampled evidenced that staff had received training relating to safeguarding, this was further confirmed by the home’s deputy manager who also stated that all staff had received training. One safeguarding referral has been made to the local authority since the last inspection of the service. Aveley Lodge DS0000017757.V371036.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, 24, 25 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables people to live in a safe, well maintained and comfortable environment, which encourages them to maintain their independence EVIDENCE: A tour of the premises was undertaken and found them to be in a good state of general repair. Repair and upkeep of the premises is undertaken by one of the two proprietors. The premises and grounds of the home were fit for there stated purpose, being comfortable and homely, well maintained tidy and safe. All of the home’s radiators had ornate guards fitted over them, to reduce the risk of service users being injured should they fall or lean against them when hot. Lighting in the home was domestic in nature and was adequate enough to Aveley Lodge DS0000017757.V371036.R01.S.doc Version 5.2 Page 19 provide service users with sufficient light to read or undertake other activities if they so wished. Accessibility to people with physical difficulties was available from a number of areas throughout the home, via patio doors with ramped access. None of the people living in the home were accessing the garden on the day of the visit, due to the time of year and the inclement weather. The laundry continues to have a carpet floor covering that was not washable, therefore a recommendation has been made in this report that it should be replaced with a surface that maybe easy to keep clean. Cleaning materials were now stored safely in a locked cupboard in the laundry room, and there is a policy in place for infection control, which is due for review in May 2009. Sampling of staff training files indicated that staff had received training in this area. Aveley Lodge DS0000017757.V371036.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 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff in the home are reported to be well trained and skilled. Staff are provided in sufficient numbers to support the people who use the service, in line with their terms and conditions, and to support the smooth running of the service. EVIDENCE: Sampling of the home’s duty rota for the period 11th August to the 14th September 2008 indicated that there are three care staff on duty between the hours of 7.am to 10.pm as a minimum, occasionally this increase to four, a part-time activities co-ordinator is also in post working four days a week. A cook is employed in the home seven days a week, with domestic staff employed five days a week. Two waking night staff provide nighttime support. The staffing levels identified from the rotas were confirmed as being correct through discussion with staff. The home’s staffing levels will need to be kept under close review, particularly where service users needs change, and the manager will need to develop a process for ensuring that this is done. Discussions with staff members indicated that they felt the staffing levels were currently sufficient to meet peoples basic care needs. Aveley Lodge DS0000017757.V371036.R01.S.doc Version 5.2 Page 21 The deputy manager reported that all care staff were now signed up for either National Vocational Qualification level 2 or 3 although, as at the previous inspection there was not any documentary evidence available to support this claim. During the course of the inspection the recruitment records for four members of staff were sampled All of the files contained the documentary evidence required under regulation including, copies of application forms, two written references, criminal records bureau check (CRB), evidence of induction and supervision, and evidence of staff training. Additional information included, contracts of employment, job descriptions, and staff handbooks. The home’s recruitment practice has improved significantly since the last inspection and was now sufficiently robust enough to ensure that people living in the home were adequately protected by the process. The staff training records of those staff whose files were sampled evidenced that training had been provided in the following area: Medication administration, deprivation of liberty, infection control, record keeping, caring for people with dementia, developing an activities programme, Adult protection (POVA), moving and handling, fire safety, emergency first aid and dementia awareness. The training record indicated that since the last inspection site visit the training of staff had been improved significantly. Aveley Lodge DS0000017757.V371036.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, 32, 33, 36 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management and administration of the home is based on openness and respect, however the home does not yet have in place an effective quality assurance system. Service users do not benefit from being supported by a staff team who are regularly supervised. EVIDENCE: The home’s registered manager has some previous experience of working and managing in the care sector, and is in the process of completing their registered managers award, in recognition of their limited experience and of recent events within the care home the manager has commissioned the support of an independent consultant to support them in moving the service Aveley Lodge DS0000017757.V371036.R01.S.doc Version 5.2 Page 23 forward. The improvements within this report are a reflection of how much of an impact this action has had on the home and the manager, and the manager is to be commended on taking this course of action. Discussion with the deputy manager and a number of staff indicated that the manager is providing them with a sense of leadership and direction, they also stated that the manager’s approach is now much more open and transparent, and that they would now feel confident and comfortable about taking any concerns or issues to them. The home now has a schedule of service users meetings and staff meetings posted on the wall in the office, which commenced in June and July of this year, a record of attendance at these meetings was kept, and minutes of the meetings were taken and circulated. Dates for further meetings are scheduled through till summer 2009. The only money held by the home on behalf of service users is personal allowance money. This is stored safely in a locked cupboard in the office and money is kept in individually named wallets. Records for three service users were sampled and found to be in order with no discrepancies in the accounting. All staff now have supervision contracts in their files, and the process of supervision has been commenced, however, at the time of the inspection visit not all staff were receiving formal supervision. We were informed that the coproprietor, registered manager and their deputy, would undertake supervision of staff every six to eight weeks. The home’s safe working practices were sampled through the viewing of the following safety certificates and reports: Environmental Health Officers report, hoist service report, fire fighting equipment report, gas safety certificate, all of which were found to be in order. A list of emergency contact numbers is kept in the office for use by staff in the event of a breakdown in any of the home’s utilities. Aveley Lodge DS0000017757.V371036.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 3 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 3 3 x x x X 3 3 2 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 x 3 2 X 3 Aveley Lodge DS0000017757.V371036.R01.S.doc Version 5.2 Page 25 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 OP7 Regulation 15 Requirement Timescale for action 31/10/08 2. OP16 22 3. OP36 18 (2) 4. OP33 24 All residents must have a care plan that covers needs identified by assessment and is reviewed to ensure residents receive support in the way they would choose. The home must ensure that all 31/10/08 complaints received are appropriately logged and investigated in accordance with the home’s complaints policy. All staff must be provided with 31/10/08 appropriate supervision to ensure that any training needs are identified. This requirement had a timescale of 31/08/07, which has not been met. The home must develop a 30/11/08 process for reviewing and keeping under review the quality of the home’s service provision. The previous timescales that have been set have not been met. Aveley Lodge DS0000017757.V371036.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP26 OP28 Good Practice Recommendations It is recommended that the floor covering in the laundry room be replaced with a surface that is easy to keep clean, as opposed to being carpeted. It is recommended that the responsible person make available certificates to confirm that staff are N.V.Q level 2 qualified. Aveley Lodge DS0000017757.V371036.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Aveley Lodge DS0000017757.V371036.R01.S.doc Version 5.2 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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