Inspection on 11/06/07 for Avenue Community Nursing Home

This inspection was carried out on 11th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Avenue Community Nursing Home 18/10/05

Avenue Community Nursing Home 08/06/05

Avenue Community Nursing Home 24/01/05

Avenue Community Nursing Home 29/07/04

Similar services:

Ashlea Mews Residential Home

Eastwood

West Lodge

Arran House

Cosin Lodge

Farmborough Court

Cragston Court

Coalway Lane Nursing Home

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

CARE HOME ADULTS 18-65 Avenue Community Nursing Home 47 The Avenue Linthorpe Middlesbrough TS5 6PE Lead Inspector Jackie Herring Key Unannounced Inspection 11th June 2007 09:45 Avenue Community Nursing Home DS0000000144.V341824.R02.S.doc Version 5.2 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 Avenue Community Nursing Home DS0000000144.V341824.R02.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 Adults 18-65. 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. Avenue Community Nursing Home DS0000000144.V341824.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Avenue Community Nursing Home Address 47 The Avenue Linthorpe Middlesbrough TS5 6PE 01642 816721 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) Avenue Community Nursing Home Limited Care Home 13 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (13) of places Avenue Community Nursing Home DS0000000144.V341824.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th October 2005 Brief Description of the Service: The Avenue Community is a 13-bedded care home for adults with mental health needs. It has been operating for approximately 25 years and is a converted Victorian property close to the centre of Linthorpe in Middlesbrough. There are eleven single bedrooms two of which have ensuite and two double bedrooms none of which are ensuite. All of the rooms do meet the size requirements. The home is situated in an urban area, very close to shops, places of worship and within easy access of public transport. The home blends in very well with the other houses in the local community. The weekly fees range from £338 - £476 depending upon assessed needs. Avenue Community Nursing Home DS0000000144.V341824.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was a key unannounced inspection and was completed in one inspection day, five inspection hours in total. As a key inspection, all of the key standards were examined. This was to check that the home meets the standards that the Commission for Social Care Inspection say are the most important for the people who use services, and that it does what the Care Standards regulations say it must. Residents were involved in discussion about their lives in the home, a number of records were looked at included resident records, medication records, staff files, training records and some maintenance records. Care staff were also interviewed and there was in-depth discussion with the manager. A number of resident surveys were also completed. Time was also spent looking around the home and informally chatting to residents. This was a very positive inspection and the inspector felt very warmly welcomed by the residents, staff and management team. There was a lot informal spontaneous discussion with the residents and a real sense of openness and inclusion. What the service does well: The residents who live at The Avenue Community are provided with a very high standard of care and are supported by a well-experienced, friendly and knowledgeable staff team. One resident said, “They help me to help myself”. Another resident said, “The staff are second to none”. “They have the skill and knowledge to support me in those areas needed”. One resident also said, “I love it here, every minute, it is just like home from home, even my relatives say this”. Individual care records are extremely well written and residents are fully involved in their individual assessment of need and plans of care. Healthcare needs, both physical and psychiatric needs are well met by the home. One resident said of the care, “They really motivate me here, I have really progressed since being here and I now feel really fine”. Another residents said, “They help me in just the right way, help me get over some hurdles”. The Avenue continues to provide residents with a lifestyle that allows for independence, choice, and personal development and firmly believed their needs were met. Staff said when asked what the home did well, “promoting independence, giving residents self worth and encouraging them to do things for themselves”. “The residents are involved with everything, it is collective decision making”. Avenue Community Nursing Home DS0000000144.V341824.R02.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. Avenue Community Nursing Home DS0000000144.V341824.R02.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Avenue Community Nursing Home DS0000000144.V341824.R02.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Resident’s have their needs fully assessed before they are admitted to the home ensuring their needs can be met. There are opportunities to spend time in the home prior to deciding whether to move in. EVIDENCE: Before anyone is admitted to The Avenue Community, there is a detailed pre admission process that takes place. Before agreeing admission the service carefully considers the needs assessment for each individual prospective person and the capacity of the home to meet their needs. The policy states, “Day visits are arranged to meet other residents, then overnight stays and weekends”, “If the procedures are successful and there is positive feedback from all other residents, the individual would be admitted into the home at their own pace and level of ease”. The Avenues own assessment is completed by a Registered Mental Nurse who has the required skill and experience to undertake this completes assessment. . Avenue Community Nursing Home DS0000000144.V341824.R02.S.doc Version 5.2 Page 9 It is clear that individuals are supported and encouraged to be involved in the assessment process. Information is gathered from a range of sources including other relevant professionals, and with the individual’s agreement. Two sets of residents records were looked at with their permission, both of which contained a copy of the care management care plan and detailed assessment of need completed by key staff. Residents confirmed that the process for admission was a good process and ensured that their needs would be met within the home. The manager and staff spoken to also confirmed the process. Avenue Community Nursing Home DS0000000144.V341824.R02.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The homes assessment and care planning process ensured resident’s needs are identified and met. Residents are consulted about all aspects of their life and were supported to be as independent as possible and are supported to take risks. EVIDENCE: Two sets of residents records were looked at, one was the most recently admitted resident, while the other was a resident who had lived in The Avenue for a number of years. The care records contained extremely detailed person centred assessments, risk assessments and care plans. The flow of information was very good. The assessments showed that the whole person and their individual needs were looked at and included areas such as, psychological well being; functional life skills; occupational /recreational profiles as well as a personal profile and psychiatric history. What was also very good was the care plan questionnaire that is completed on admission to the home and covers all areas of daily living skills, preferences, choices and lifestyle agreements. An example of this included, “hygiene – he/she prefers Avenue Community Nursing Home DS0000000144.V341824.R02.S.doc Version 5.2 Page 11 to have a shower in the morning, three times a week with total privacy and the staff will help with the laundering of clothes”. Religious and cultural needs are also considered in all of these areas. The assessment includes the resident’s perceptions of their needs as well as the staff perceptions and throughout the documentation there is clear evidence of the residents involvement and agreement. One of the resident’s records contained the following staff comments, “We hope he/she will become more independent, integrate more into the community therefore improve his/her quality of life. In the future it is hoped that he/she will be discharged to live independently. He/she has made so much progress”. The residents comments was, “I hope I am going to be able to live on my own, not far from here, because everyone here are my friends and I want to keep in touch”. Needs specific care plan are very well written and detail what it to be achieved how is to be achieved and who is to be involved. Resident who were spoken to said that they were fully aware of their individual records and that they had been discussed with them. The care plans are being evaluated every month and are amended or discontinued when things change. Each resident have their needs fully reassessed on an annual basis, with their involvement. One resident said of the care, “They really motivate me here, I have really progressed since being here and I now feel really fine”. Another residents said, “They help me in just the right way, help me get over some hurdles”. The documentation continues to contain a very good life history, has clear links to multi agency involvements and clearly demonstrates that individual residents mental health, emotional and physical health needs are being met. Individual aspirations were also recorded and risk management strategies are in place to support independence and personal development and growth. Avenue Community Nursing Home DS0000000144.V341824.R02.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are treated with respect and their lifestyles are very much individualised and underpinned by appropriate social and recreational activities. Residents’ benefit from maintaining personal relationships and have their right respected. Meals are provided to a good standard within a suitable environment. EVIDENCE: Residents said that they had the opportunity to be involved in a number of social and recreational events if they so wished. Some of the residents regularly attended a local day centre, whilst others were able to freely go to the local shops or into town. In the residents files looked at, they had an individual weekly plan, which detailed their social and recreational activities. Avenue Community Nursing Home DS0000000144.V341824.R02.S.doc Version 5.2 Page 13 During discussion with residents and the manager, the most recent holiday was talked about, which was a trip to Folkestone with visits to France and Belgium. In the manager report about the holiday, the following comments were made, “It was a pleasure to see the look on their faces when we went into the Channel Tunnel for the first time, they thoroughly enjoyed the trip”, a resident commented, “This is brilliant, I haven’t been on holiday for eleven years”. Staff confirmed that there were regular residents meeting and that they were consulted on a range of matters, including meals and holidays. The minutes from all of the meetings were on display on the notice board in the dining room and included copies of the staff and health and safety meetings. A staff member said, “We are all one, we all make the decisions about life in the home, yes, it is extremely consultative”. They also said of what the home did well was, “promoting independence, giving residents self worth and encouraging them to do things for themselves”. “The residents are involved with everything, it is collective decision making”. During discussion with staff and residents, it was confirmed that they were well able to maintain links with family and friends. One of the residents talked of the regular visits they were now having with their family, with weekend leave from the home to stay with them. Meals were described as very good and residents were actively involved in the menu planning, which takes place on a weekly basis and includes preferences and choice from all of the residents. A large bowl of fresh fruit was observed in the dining room for everyone to help himself or herself. During the inspection, lunch was being served, which was a very light informal lunch of sandwiches with residents being offered a range of choices. The evening meal on the day of the inspection was a BBQ, which everyone was looking forward to. One resident said of the meals “All the grub is really nice, Sunday dinner is the best, you have a choice and then there are other options as well”. It was also observed that residents were free to go into the kitchen and make themselves drinks and light snacks, this was also confirmed through discussion with residents. On commencement of the inspection there was a resident in the kitchen making their own breakfast. Avenue Community Nursing Home DS0000000144.V341824.R02.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20, 21 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Healthcare and personal care needs are met by staff who provide support in a sensitive and flexible manner in accordance with the wishes of the individual resident. Appropriate healthcare professionals provide advice and additional support for the residents and staff. EVIDENCE: The two sets of residents records looked were extremely well written and contained detailed information about the individual residents, their assessed needs and lifestyles. The records detailed involvement of GP, Consultant Psychiatrists, Care Programme Approach reviews and all health related matters. The home works closely with external professionals and specialists for advice and support to help the service user and the homes’ staff. Residents confirmed that both their physical and mental health needs were well met within the home. Staff also said that as well as meeting residents psychiatric health needs residents also had the medical needs met and said that they attended for appointments such as mammograms. A staff member spoken to, said, “The residents are very understanding of each other, they show each other empathy, they feel for each other”. One of the Avenue Community Nursing Home DS0000000144.V341824.R02.S.doc Version 5.2 Page 15 resident who had lived at the home for a number of years had recently died. This had been handled with sensitivity and the residents freely spoke about this during the inspection and about how they were missing them, but also about how they had been supported through this sad time. The Avenue is a care home with nursing as such; only the qualified nurses have any involvement with the medication. Although the qualified nurses were trained to safely handle and administer medication through their nurse training, the manager has also arranged for them to complete further training with a view to refreshing and updating, as such, all qualified nurses have completed the distance learning on Safe Handling of Medicines course and certificates were made available to confirm this. The manager said that one of the qualified nurses is responsible for the ordering of monthly medication and described a good system. Very detailed policies and procedures were in place to support the systems in place with The Avenue and they had been reviewed and updated in January of this year. The storage of medication is adequate for the size of the home and the amount of medication to be stored. Arrangement and storage is available should it be needed for controlled drugs or drugs that needed to kept in a fridge. One of the residents who records were looked at in detail self medicates. A risk assessment and management plan was in place for this and the resident confirmed that the staff carry out regular check with them to make sure that it is working well. They have the appropriate lockable facility for the storage of their own medication. Avenue Community Nursing Home DS0000000144.V341824.R02.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had a suitable complaints system and policies and procedures to protect residents from abuse. All staff had received training in the Protection of Vulnerable Adults. EVIDENCE: Residents and staff confirmed they were well aware of the complaints procedure. One resident spoken to said, “If needed I would raise concern with any one of the staff, they all have the right attitude and definitely treat you with respect”. Another residents said, “I would go to the staff if I had any concerns or complaints and I have seen the complaints procedure”. The pre inspection questionnaire detailed that there had been no complaints since the last inspection, which was also confirmed by the manager. There was evidence within individual staff training records that they had received Protection of Vulnerable Adult and No Secrets training. During discussion with a staff member this was confirmed and they were very clear about the action they would take should the need arise. Avenue Community Nursing Home DS0000000144.V341824.R02.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s benefit from a well-maintained, comfortable and homely environment in which to live. EVIDENCE: The Avenue Community provides a warm, relaxed and homely place for people to live. It is very clean and well maintained and it is clear that there is a programme for continuous improvement and redecoration. Since the last inspection, a new stair and hallway carpet had been laid, the kitchen has been refurbished and the garden area improved with the erection of fence, increasing the paved area for seating and also increasing the privacy in the garden. Avenue Community Nursing Home DS0000000144.V341824.R02.S.doc Version 5.2 Page 18 Several areas of the home were visited and all areas of the home, including the kitchen, were accessible to residents. Bedrooms that were visited were comfortably and appropriately furnished and had been personalised by the inclusion of personal belongings such as pictures, posters, and photographs, TV, CD player and some residents had their own furniture. The Avenue is extremely homely with sufficient internal communal space and there was a real sense of comfortable family homes. One of the residents said, “I have a lovely room with my own furniture, I have made it like home and had it decorated”. All of the bedrooms doors had locks and residents were observed locking their rooms and keeping their own keys. The resident’s permission was obtained before any of the rooms were visited. All areas of the building were centrally heated and radiators had been covered with suitable guards to ensure a low surface temperature. Where there are attractive portable heaters in place, risk assessments had been completed and were being reviewed regularly. Water temperatures were controlled to guard against scalding. Lighting was domestic in nature and emergency lighting had been provided throughout the home. The numbers and suitability of lavatories and bathing facilities met the National Minimum Standard. The assessed needs of residents were being met without the provision of environmental adaptations or specialist disability equipment Avenue Community Nursing Home DS0000000144.V341824.R02.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff numbers and skill mix are appropriate for the resident’s needs. Staff are competent to do their jobs and residents are protected and supported through the home’s recruitment procedures. EVIDENCE: There is very little staff turnover at The Avenue and no new staff have been employed since the last inspection. The recruitment policy and procedure contains the appropriate information and it was confirmed that if new staff were employed, the correct procedure such as, obtaining two references, Criminal Records Bureau and Protection of Vulnerable Adults checks and clarifying employment history prior to employment would be completed. The policy contained the statement, “All recruitment will reflect the anticipated needs of the residents and the home” and it covered a full range of equal opportunities information. The Avenue is highly selective, with the recruitment of the right person for the job being more important to the filling of a vacancy and the residents are also involved in this process. Avenue Community Nursing Home DS0000000144.V341824.R02.S.doc Version 5.2 Page 20 The staff duty rota showed that there is always a Registered Mental Nurse on duty and they are supported by a varying number of care staff, depending upon the needs of the residents and what might be happening on certain days. The pre inspection questionnaire detailed that 80 of staff are trained to NVQ Level 2 or above, which is excellent. A number of staff have also completed NVQ Level 3 and one staff member is underway with NVQ Level 4. In the files looked at, there were individual training records and since the last inspection included training such as Fire, Moving and Handling, POVA, Care Planning, Safe Handling of Medicines and Equality and Diversity. All staff are due to attend Mental Capacity Act training within the next few weeks. Resident spoke very highly of the staff team and believed that they supported them to meet their needs. One resident said, “They help me to help myself”. Another resident said, “The staff are second to none”. “They have the skill and knowledge to support me in those areas needed”. One of the staff members spoken to clearly had a very good understanding of mental health needs. All of the staff also have clear roles and responsibilities within the home for example one staff member is responsible for the medication management, another for the health and safety of the home and another for the financial matters of the home. Avenue Community Nursing Home DS0000000144.V341824.R02.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The manager and management team continue to provide very good leadership to the staff team and continuously strives to improve standards within the home ensuring that resident’s needs are well met. Good systems are in place for the handling of resident’s personal allowances and there is also a good range of quality assurance systems. Good service and maintenance arrangements are in place and in good order ensuring health and safety is promoted. EVIDENCE: The manager of The Avenue is a registered mental nurse and has the appropriate qualifications, skills and experience to manage the home and has done so for in excess of 20 years. She provides strong leadership and operates a very open management style, which is inclusive and enabling. As Avenue Community Nursing Home DS0000000144.V341824.R02.S.doc Version 5.2 Page 22 well as the manager, there is a management team with individual members of this team having responsibility for different management functions, such as the finances, which work very well. The management of the home was described as very open, very approachable and one where everyone could express a point of view. One resident said, “I love it here, every minute, it is just like home from home, even my relatives say this”. Another resident said, “I love it here, particularly the staff, who are second to none. It is so easy going, just like your own home”. A staff member said, “It is definitely homely here, we all look after each other and we treat each other as a family and show mutual respect”. All of the residents look after their own finances and most of them have their own bank accounts. The home is responsible for giving some of the residents their full weekly allowance and there is a sound system in place for this, which includes the resident’s signature and the signature of two staff members. A number of quality assurance reports were looked, the last one being dated May 2007, the focus of this was the health and social support given to residents. In February 2007 the surveys focus was about individual bedrooms, with the outcome being how to support the residents to be more independent and to take responsibility for their own rooms. Other reports were also looked at and the summary reports are available and accessible to the residents. There was also report from the most recent holiday, which was an excellent report that detailed the experience of all of the residents and also some areas for improvement when planning the next holiday. Other quality assurance systems are in place including the monthly environmental audit, health and safety meetings and audit of the policies and procedures. Avenue Community Nursing Home DS0000000144.V341824.R02.S.doc Version 5.2 Page 23 Discussion took place with the staff member who is responsible for managing the health and safety of The Avenue. They confirmed that regular health and safety meetings take place, which are minuted and the minutes were observed to be available on the notice board. A maintenance schedule is in place and this detailed when equipment was last serviced and when it was next due, this included equipment such as the fire system, gas and portable appliance tests and showed that all equipment had been services and documentation was available to support this. An annual training programme was also looked at which detailed all of the mandatory training and individual staff records showed when they last received the training and when it was next due. This as well as discussion with the manager and staff confirmed that mandatory training was regular delivered to all staff. Residents are also involved in some level of fire training. Avenue Community Nursing Home DS0000000144.V341824.R02.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 Adults 18-65 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 X 34 3 35 X 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 4 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 3 3 4 X 4 X X 3 X Avenue Community Nursing Home DS0000000144.V341824.R02.S.doc Version 5.2 Page 25 No Are there any outstanding requirements from the last inspection? 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. Standard Regulation Requirement Timescale for action 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 YA20 Good Practice Recommendations When it is necessary to handwrite medication on the Medication Administration Record this should be signed for and witness to ensure that the information is accurate and will therefore protect the wellbeing of the residents. Avenue Community Nursing Home DS0000000144.V341824.R02.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Darlington Area Office No. 1 Hopetown Studios Brinkburn Road Darlington DL3 6DS 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 Avenue Community Nursing Home DS0000000144.V341824.R02.S.doc Version 5.2 Page 27 - 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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