Inspection on 03/03/08 for Aveley Lodge

This inspection was carried out on 3rd March 2008.

CSCI found this care home to be providing an Poor 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 02/09/08

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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Aveley Lodge Abberton Road Fingringhoe Colchester Essex CO5 7AS Lead Inspector Neal Cranmer Unannounced Inspection 3rd March 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.V360366.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.V360366.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 And Mr Michael parmenter Manager post vacant Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21) of places Aveley Lodge DS0000017757.V360366.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 September 2007 Date of last inspection Brief Description of the Service: The home is owned by Mr R Parmenter, who is currently acting as the manager of Aveley Lodge. 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 per week, with an additional charge being made for hairdressing. This information was provided verbally to the inspector at the time of the inspection. Aveley Lodge DS0000017757.V360366.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 zero star. This means the people who use this service experience poor quality outcomes. This report is the outcome of a key unannounced inspection of the service, which took place on the 3rd of March 2008. The primary purpose of this visit was to check compliance of a number of statutory requirements which had remained outstanding for a period of time, and which were now of concern to the Commission for Social Care inspection. For this reason the inspection was undertaken by two inspectors. The inspection process included: discussions with three people living in the home, one relative, three staff members, the manager and proprietor. Comments from all of those spoken with are included within the main body of this report. In addition to the above discussions, a range of documentary evidence was sampled, this included: care plans, policies and procedures, recruitment records, and staff training records. A tour of the premises was also undertaken during the inspection visit. What the service does well: What has improved since the last inspection? Thirteen statutory requirements were made at the inspection of 3rd September 2007, of these twelve remained unmet from this inspection. This reflects little in the way of improvement and is now of serious concern to the Commission for Social Care Inspection. Consideration is now being given to taking enforcement action. Aveley Lodge DS0000017757.V360366.R01.S.doc Version 5.2 Page 6 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. Aveley Lodge DS0000017757.V360366.R01.S.doc Version 5.2 Page 7 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.V360366.R01.S.doc Version 5.2 Page 8 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 and 6. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use this service can expect to have information available to help them make an informed decision about living in the home but cannot be assured that there will be an assessment of their needs undertaken before being offered a place. EVIDENCE: The responsible person has a statement of purpose that has details of the accommodation and services available in the home. Some of the information requires updating including the change of proprietors of the home and the change of name from National Care Standards Commission (NCSC) to the Commission for Social Care Inspection (CSCI). The admission procedure states that prospective residents are admitted after an assessment of need Aveley Lodge DS0000017757.V360366.R01.S.doc Version 5.2 Page 9 that has shown that the home can meet their needs. Potential residents are offered the opportunity to visit the home and the first month is considered a trial period for both parties to ensure the right decisions are made by the resident and the other people living in the home. The file of one resident had a letter from one of their relatives thanking the staff for facilitating a visit to the home prior to offering the person a place. The files of five residents were inspected in the course of the day. Only one had an identified pre-admission assessment document and that was not dated so it was difficult to establish when the information had been collected. The document covered areas of support such as general behaviour, continence, mobility and a medical history. The manager keeps a folder of initial enquiry forms that are completed when a relative or potential resident first makes enquiries about moving into the home. These forms contain information about next of kin contact details, the resident’s GP and the reason the person is making enquiries about a care home placement. This service does not offer intermediate care. Aveley Lodge DS0000017757.V360366.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. People who use this service cannot be assured that they will have a care plan in place to assist staff to meet their needs or that they will be protected by the present medication management. EVIDENCE: The files of five residents were seen and all contained some assessment of the resident’s needs and some risk assessment forms. A number of other forms recording information such as weight, food intake and activities undertaken were also seen but many were incomplete and not signed or dated. Two residents who had wounds that required dressing by the community nurse had body map charts that had no entries on them. Aveley Lodge DS0000017757.V360366.R01.S.doc Version 5.2 Page 11 The admission assessment forms covered mobility, diet, general health and past medical history, social history, hobbies and mental health. Each file also contained a resident’s profile that covered personal hygiene needs, continence, diet, night needs, the daily routine and communication. When completed these forms contained the information required to write a care plan but none of the five files seen had a care plan to help staff meet the residents’ needs. All the files had a manual handling risk assessment completed and a nutritional assessment. The score for one nutritional assessment was 24. A score of over 18 was ‘very high risk’ and the interaction advised was to ‘seek diatetic advice’. The resident had no care plan for managing this need and when asked the manager said they had not requested any professional support. The room of one resident was seen and there were bed rails without protective bumpers on the bed. The manager said there would be a risk assessment for the use of the bedrails in the resident’s file. The relevant file was seen and recorded on a form titled ‘infringements’ was the fact that bed rails were being used. It was not a risk assessment of the potential dangers and restrictions for the resident by the use of the rails. As there was no care plan no other interventions were recorded for use or management of bed rails or the reason for their use. The files all contained a sheet for recording the input of health professionals such as the GP, community nurse, physiotherapist, dentist and out patients appointments. There was space to record treatment prescribed and any changes made in the medication regime. These sheets were inconsistently completed with some details recorded in the daily records making it difficult to access information quickly. A community nurse spoken with during the day said that any referrals received by their team from the home were appropriate and timely. Staff were knowledgeable about the residents and their needs and always welcoming. Part of the lunchtime medication administration round was followed. The home uses dossett boxes filled by the local pharmacy to the prescriptions for each resident. However a number of tablets are not suitable to be dispensed into dossett boxes and the pharmacy supply these in the original boxes. The mixture of dossett boxes and containers in the trolley looked very untidy and muddled. The carer had to spend time looking for the correct boxes during the round. The medication policy was seen and needs to be amended to give full guidance for staff on all aspects of ordering, storing, administering and disposing of medicines. Guidance on the management of controlled drugs, covert administration of medication and the altering of medicines from the format licensed by the manufacturers should be included. Aveley Lodge DS0000017757.V360366.R01.S.doc Version 5.2 Page 12 The medication administration records (MAR sheets) were seen and showed a number of gaps in the signature boxes making it difficult to know whether the resident had received their medicine or not. Some boxes had a diagonal bar drawn through them. When the carer was asked what that meant they were unable to say and again it was not clear if the medicine had been given or not. One instruction for Oxybutinin to be given once a day (OD) had been signed for the previous three days as being given twice a day (BD). Residents were asked if they wished for painkillers if there was a choice of dose and helped to manage to take the tablets with fresh drinks and the use of a teaspoon if needed. The carer dispensed tablets from the dossett boxes and cartons into their hand before transferring them to a medicine pot. A nontouch technique should be used to prevent contamination. When asked about training to perform the medication administration round the carer said they had had ‘Safe Hands’ training but could not remember when it was. On the MAR sheets it was noted that the morning dose of morphine sulphate tablets (MST), which is a controlled drug (CD), for one resident had been omitted. The carer said they had run out of tablets but the manager was collecting some from the pharmacy later. The manager later was asked to show the storage and recording for CDs. The box of MST was in the medicine trolley and the manager said they had no CD register to record that the drugs were in the home. They said two people checked CDs when they were dispensed but there was only one signature on the MAR sheets. It was explained that CDs fall under the Misuse of Drugs Regulations and are required by law to be stored and recorded in specific ways. The manager then said they had watched a training video recently that had covered these precautions. Aveley Lodge DS0000017757.V360366.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13,14 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use this service can expect to be encouraged to maintain contact with family and friends but cannot be assured that they will be offered meaningful pastimes. EVIDENCE: The five residents’ files seen all had contact details of the person’s next of kin and the daily records contained references to visits from friends and family. A number of visitors were seen during the day spending time in the main lounge or in resident’s own rooms with people. People spoken with said they were free to visit at any time and always made welcome. During the afternoon people have access to the kitchen to make a hot drink for themselves or their relative. If people want a drink in the morning a small area in one corridor has been equipped with drink making utensils to prevent potential accidents in the kitchen during the busy period preparing lunch. Aveley Lodge DS0000017757.V360366.R01.S.doc Version 5.2 Page 14 In the files there was some evidence that residents’ interests and hobbies had been recorded. One entry said the resident liked to celebrate all Protestant festivals, enjoyed rugby events and the BBC Proms. A number had recorded spending time with family as one of the occupations they most enjoyed. Two files contained a form to record any involvement by friends or relatives in the support of the resident. Both forms were blank although it was recorded in one daily record that the resident’s spouse visited regularly. One resident spoken with, who had a strong Christian faith, said the home did not facilitate religious services for residents who found it difficult to attend a local church. A visiting health professional also said that they were unaware of any services in the home. They commented that in the nice weather they had not seen any residents using the garden, which was a shame as the views were splendid. During the day of inspection no organised activities were observed. The television was on constantly in the main lounge but most residents were dozing for the main part of the day. When staff were able to sit to complete records they did not sit with residents but in the empty dining room. The kitchen was visited after lunch was found clean and tidy. Records of temperatures of refrigerators and freezers showed they were working within safe food storage limits. The door to the kitchen also gives access to two further storage rooms. One contained refrigerators and shelving for storage. The items stored were a mixture of food and a quantity of cleaning products. The second room was used as a staff room and also stored some food and some residents’ files. All areas could be accessed although there was a notice on the kitchen door asking that people did not enter the kitchen until after lunch. The menus are recorded in a book kept in the kitchen. The entries were limited so on 22/2/08 the lunch was, ‘fish, chips and peas’. No dessert was recorded. On 3/3/08 the entry was, ‘sausages’ and nothing else and the next day it was, ‘chicken’. Tea was generally a mixture of sandwiches with cake and crisps. Residents spoken with said the food was all right and they had enough. One carer was observed standing over a resident sitting in an armchair while assisting them with their lunch. This does not suggest that people are treated in a dignified way. Aveley Lodge DS0000017757.V360366.R01.S.doc Version 5.2 Page 15 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 this service can expect complaints to be taken seriously and investigated but cannot be assured that the most up to date guidance to protect people from abuse is available. EVIDENCE: The policy folder contained a copy of the complaints procedure for the home but no copy was seen on display during the day. The policy needs updating to refer to CSCI not NCSC. The complaints log contained three complaints made since the last inspection. One complaint was about the standard of food, one concerned a carer’s attitude and the third was about a lack of communication from the home in relation to a prescription of antibiotics for a resident. All the complaints had been investigated and the complainants received a written response. The guidance for the management of any protection of vulnerable people incidents was also in the policy folder. It needs to be updated to reflect the most recent guidelines called, ‘Safeguarding Adults’. The procedures for dealing with an incident have changed from those in the policy folder and staff should have up to date information to follow. Aveley Lodge DS0000017757.V360366.R01.S.doc Version 5.2 Page 16 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 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use this service can expect to be supported in an environment that is homely, comfortable, and well maintained, and which is also kept clean and tidy. However people may not be assured that practice in the home always safeguards their health and welfare. 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. Aveley Lodge DS0000017757.V360366.R01.S.doc Version 5.2 Page 17 The grounds of the home were tidy and safe, and were accessible to people from a number of areas throughout the home, via patio doors with ramped access for those who were less mobile, or required the use of a wheelchair. 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 policy on infection control stated that the most important precaution was good hand washing using liquid soap and paper towels. During the tour of the home it was noted that liquid soap and paper towels were not available in the laundry, bathroom and one of the toilets seen. A cloth towel was hanging in the staff toilet. The bathroom contained a selection of toiletries that could have been left by residents but should have been returned to their rooms. The laundry, which was unlocked because the laundry worker was coming and going hanging washing in the garden, had a carpet floor covering that, was not washable. A full bottle of bleach was found on the floor near the sink unit. As identified at the previous inspection cleaning materials when not in use must be locked away, as they may pose a significant risk to people living in the home. The manager said that the electricity circuits in the home had recently been upgraded to accommodate new industrial type washing machines. Aveley Lodge DS0000017757.V360366.R01.S.doc Version 5.2 Page 18 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 poor. This judgement has been made using available evidence including a visit to this service. People who use this service cannot be assured that their needs will be met by staff who have received appropriate training for their roles, furthermore they cannot be assured that the home’s recruitment practice is sufficiently robust enough to protect them. EVIDENCE: Staff who provide personal care at the home are all aged over eighteen, and no member of staff is left in a position of being in charge under the age of twenty-one. Sampling of the home’s duty rota over a two week period indicated that there are three care staff on duty between the hours of 7.am to 10.pm. A cook is employed in the home seven days a week, with domestic staff employed four days a week. Nighttime support is provided by two waking night staff. Discussions with staff members indicated that they felt the staffing levels were adequate to meet peoples basic care needs, but did not provide scope for any quality time. This fact was reiterated during discussions with people living in Aveley Lodge DS0000017757.V360366.R01.S.doc Version 5.2 Page 19 the home and visiting relatives, who spoke of staff being rushed of there feet, rushing from one task to another. Although they were quick to point out that carers were always polite and respectful. The manager reported that 50 of the care team held National Vocational Qualifications, although no evidence was provided to support this claim. During the course of the inspection the recruitment records for three members of staff were sampled, two of the three files sampled contained all of the documentary evidence required. The third file sampled which was that of the most recent person employed by the home only contained one written reference, and the CRB (Criminal Records Bureau Check) had not been undertaken by the home, but the employee’s previous employer, this practice is no longer acceptable, having ceased in July 2004. The home’s recruitment practice is not sufficiently robust enough to ensure that people living in the home are adequately protected. Although the staff files sampled indicated a basic level of training, the level of training provided is not sufficient to ensure that staff, are adequately skilled to meet the needs of the people living in the home. Aveley Lodge DS0000017757.V360366.R01.S.doc Version 5.2 Page 20 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, 35, 36, 37 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use this service cannot be assured of living in a home which has a clear management ethos, and which is run in their best interests, furthermore practices in the home do not adequately safeguard people’s health and safety. EVIDENCE: The home continues not to have a registered manager who is registered with the Commission for Social Care Inspection, although an application has been received and is in the process of being processed. The acting manager is however in the process of undertaking their registered managers award. Aveley Lodge DS0000017757.V360366.R01.S.doc Version 5.2 Page 21 Discussion with staff indicated that they felt the acting manager was approachable, but were less confident about how any concerns they raised might be responded to. The staff spoken with were also of the view that the home is not managed in an open and transparent way, they felt they were often kept in the dark about issues that they perhaps needed to be aware off. The home’s quality assurance process could not be sampled during this inspection as much of the documentary evidence required was off site. The acting manager was reminded that all such documentation should be on site at all times available for inspection. The home manages the personal allowances for a number of people living in the home, records sampled relating to two people were inspected and found to be in order, providing a clear audit trail of expenditure. A process for staff to receive formal supervision has been in place for some time now, however discussion with staff indicated that they are not receiving any formal supervision. Staff spoken with had varied experiences of supervision ranging from four monthly to not for a number of years. The manager was reminded of the importance of supervision, and of the need for staff to be provided with regular formal supervision. The home continues to need to ensure that records relating to people living in the home are maintained as defined under Regulation 3 of the Care Homes Regulations. Although the home’s safe working practices are generally good, evidence was still found at the inspection of cleaning materials being left in areas where people may unintentionally wander. Cleaning materials when not in use or with a member of staff need to be locked away in a safe and secure area. Aveley Lodge DS0000017757.V360366.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 2 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 2 X 3 1 2 2 Aveley Lodge DS0000017757.V360366.R01.S.doc Version 5.2 Page 23 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 OP29 Regulation 18 Requirement The responsible person must ensure that all the documentary evidence pertaining to staff recruitment is held on file as per the requirements of Schedule 2 of the Care Homes Regulations to ensure that residents are protected. The previous timescales of June 2005, 31st October 2005 and 28th February 2006 and 28/08/06 and 31/03/07 and 31/08/07, and 3rd September 2007 were not met. Provision must be made for the appointment of an individual to manage the care home, to ensure that the home is managed appropriately. The previous timescale of 31st March and 31/08/06 and 31/03/07 2006, 31/08/07 and 3/09/2007 were not met. All staff must be provided with DS0000017757.V360366.R01.S.doc Timescale for action 31/05/08 2. OP31 8 31/05/08 3. OP36 18 (2) 31/05/08 Page 24 Aveley Lodge Version 5.2 formal supervision to ensure that any training needs are identified. The previous timescales of June 2005, 31st October 2005 and 31st March 2006, 31/08/07 and 3/09/2007 were not met. 4. OP30 18 (i) All staff must receive necessary training in safe working practices to ensure that service users and their health and safety are protected and promoted. The responsible person must develop a process for reviewing and keeping under review the quality of the home’s service provision. This is to ensure that the home is run in the best interests of the people living in the home. The previous timescales that have been set have not been met. The responsible person must ensure that all staff receive training appropriate to the work that they are to perform. This relates specifically to the need for all staff to be trained in the administration of medicines. This is to ensure that people living in the home are protected. The previous timescale set of the 31/08/07, and 3/09/07 was not met. The responsible person must make provision for providing recreational activities that are suitable to the needs of the service users. The previous DS0000017757.V360366.R01.S.doc 31/05/08 5. OP33 24 31/05/08 6. OP9 18 (ci) 31/05/08 7. OP12 16 (n) 31/05/08 Aveley Lodge Version 5.2 Page 25 timescales set have not been met. The previous timescales set was not met. 8. OP7 15 (1) The home must ensure that care 30/05/08 plans adequately reflect all of the needs of the individual, to ensure that residents are appropriately supported. Previous timescales set were not met. All staff must receive necessary training in safe working practices to ensure that service users and their health and safety are protected and promoted. The responsible person must ensure that residents are supported in a manner, which respects their privacy and dignity. The responsible person must ensure that resident’s are provided with a wholesome and nutritious diet. 31/05/08 9. OP18 18 (i) 10. OP10 12 (a) 31/05/08 11. OP15 16 (i) 31/05/08 12. OP26 23 (l) The responsible must make 31/05/08 provision for the suitable storage of cleaning materials used in the home. This is to ensure that risks to people living in the home are minimised. Previous timescales set were not met. The responsible person must ensure that the home is at all times staffed in appropriate numbers by skilled and competent staff. This is to ensure that the needs of people living in the home can be met. DS0000017757.V360366.R01.S.doc 13. OP27 18 (1) 31/05/08 Aveley Lodge Version 5.2 Page 26 14. OP37 17 (1) The responsible must maintain in 31/05/08 respect of each resident the records specified under Schedule 3 of the Care Homes Regulations. 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 OP28 Good Practice Recommendations It is recommended that the responsible person make available certificates to confirm that staff are N.V.Q level 2 qualified. It is recommended that the responsible person look at ways in which the home should be managed in an open and transparent way. 2. OP32 Aveley Lodge DS0000017757.V360366.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. 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