Inspection on 25/01/06 for Avenue House

This inspection was carried out on 25th January 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Avenue House 01/03/07

Avenue House 23/10/06

Avenue House 04/08/05

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Avenue House Avenue House 26 Clifton Road Tettenhall Wolverhampton West Midlands WV6 9AP Lead Inspector Bhag Jassal Unannounced Inspection 25/01/06 10:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Avenue House DS0000064388.V279796.R01.S.doc Version 5.1 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. Avenue House DS0000064388.V279796.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Avenue House Address Avenue House 26 Clifton Road Tettenhall Wolverhampton West Midlands WV6 9AP 01902 774 710 01902 77 47 12 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) West Midlands Residential Care Homes Ltd Mrs Jacqueline Stanford Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21) of places Avenue House DS0000064388.V279796.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered as a care home for older people subject to the provider meeting the Conditions of Registration in Appendix 1 dated 17/6/05. 4th August 2005 Date of last inspection Brief Description of the Service: The home is a large detached Grade 2 listed building approximately 143 years old. The home stands in two and a half acres of lawns and woodland. The home is within a short distance of Tettenhall Village where the amenities include a post office, shops and a public house. The home has been completely refurbished, adapted and recently extended for its present use as a residential care home for 21 older people. There are two double bedrooms and 17 single bedrooms, four of which have en-suite facilities, two lounges, a dining room, laundry, kitchen, staff room and Registered Managers office and a staff training room. There is a large car park and garden. Avenue House DS0000064388.V279796.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and started at 10.30 am and lasted 7 hours. 20 places were occupied and one bed remained vacant. The main purpose of the inspection was to check the progress made by the home regarding the recommendations and requirements made in the last inspection report dated 4 August 2005. The inspection included discussions with the service users, the staff and senior carers in – charge of the shifts. The daily routine were observed and service users and staff records, policies and procedures were examined. Inspection of premises both inside and outside and facilities were also undertaken. The fullest co-operation was given to the Inspector by the Senior Carers incharge of the shifts. What the service does well: The home is registered for 21 older people. The home makes every effort to provide individuals with a good standard of care to meet the assessed needs following a care plan. The home has a good key worker and staff supervision system in place. The home communicates well with the families/friends and representatives of the service users. The visitors’ book indicated a lot of activity. The service users spoken with said that they are happy and content with living in a homely and caring place. Service users were in the two lounges engaging in their daily routines and activities and they further commented that they were comfortable and satisfied with the care provided. The atmosphere within the home was observed to be relaxed, comfortable and friendly. The friendly rapport was also observed between service users and staff. Meals are varied, well balanced and presented to meet each individual’s choices, preferences and requirements. The home provides a good standard of accommodation, which is being maintained safe, secure and of a good standard. However, during the inspection, it was noted as a serious concern that the hot water system failed to provide hot water at the required temperature level of close to 43 Degrees C in all the hot water outlets throughout the care home. Avenue House DS0000064388.V279796.R01.S.doc Version 5.1 Page 6 The senior carers in-charge of the shift contacted the Registered Provider and he responded positively and asked the senior staff to contact the Plumber immediately. The Commission for Social Care Inspection (CSCI) received a written letter/fax dated 26 January 2006 from Avenue House, which confirmed that the above matter has been rectified satisfactorily and hot water in all hot water outlets has been restored at the required level of close to 43 Degrees C. In addition, the two portable electric heaters, which were posing health and safety risks were removed from two service users’ bedrooms. What has improved since the last inspection? What they could do better: The home must continue to update the service users’ needs assessments, risk assessments and care plans. The Registered Manager must ensure the quality and details of the daily care (day and night) records are improved rapidly. Those members of staff who as yet have not received training in safe working practice topics and sage handling of medication must do so as a matter of priority. This training would enable staff to improve further their care practices Avenue House DS0000064388.V279796.R01.S.doc Version 5.1 Page 7 and professionalism. There are a number of issues relating to the environment, which must be addressed as a matter of priority in order to have a safe and comfortable environment for service users, staff and visitors. The Registered Provider and the Manager must take appropriate and urgent action to provide adequate ancillary staff to cover domestic and laundry duties at the weekends and catering staff cover in the evenings. The home must progress further its Quality Assurance annual development plan and outcomes for service users. Overall the home has made steady progress since the last inspection dated 4 August 2005. 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. Avenue House DS0000064388.V279796.R01.S.doc Version 5.1 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 Avenue House DS0000064388.V279796.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 and 4 The home has a comprehensive needs assessments procedure providing an effective assessment, suitable, evaluation and its ability to meet the assisted needs of both privately funded service users and those placed by the Local Authorities – which needs updating. All the service users are given written contracts/statement of terms and conditions on admission to the home. EVIDENCE: There was evidence on service users’ individual files to show that all the service users are provided with a written contract/statement of terms and conditions of residence at the time of admission. A sample of three service users’ care plans and files were thoroughly examined at the inspection. All contained evidence that the service users receive the benefit of a comprehensive assessment prior to admission. The Senior Carers stated that the Registered Manager - Mrs Jacqueline Stanford carries out assessments on both self-funded service users and those placed by the Local Authorities. The Assessment details are documented on the service users’ care Avenue House DS0000064388.V279796.R01.S.doc Version 5.1 Page 10 plans. Care Plans are drawn up by the senior staff with the assistance from the service users and their families and where appropriate other professionals. However, it was noted that the needs assessments and risk assessments were in need of updating. The Senior Carers stated that in conjunction with the Registered Manager they will review and update all the service users’ needs assessments and risk assessments by mid – February 2006. The home has a good admissions procedure, which is made available to all prospective service users and their relatives and/or representatives. The service users and/or their relatives can visit the care home prior to admission. If they indicate that the care home is able to meet the needs of the prospective service users then the home formally confirms in writing whether or not it can meet the assessed needs of the prospective service users. Once this is agreed between all the parties concerned, then the placements take place on a 28 days trial period. Avenue House DS0000064388.V279796.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 and 9 The staff within the home are aware and sensitive to the needs of each and all service users and meet their needs in a professional manner. There is clear and consistent care planning system in place, which provides the information the staff requires to meet the service users’ health and care needs. EVIDENCE: It was evidenced that all service users undergo a comprehensive assessment of their needs prior to the care home. A care plan is produced, which is based on the assessment of needs. The home operates a key worker system, which helps to ensure that the recommendations arising from the care plans and monthly reviews are implemented. Three service users’ care plans were examined in detail and it was noted that the short-term and long-term goals and appropriate interventions required to put them into action to meet the individual service users’ needs are identified. It was noted that the care plans need to be updated and reviewed on a monthly basis, signed and dated. The daily care (day an night) recording formats were examined and it was noted that the quality and details of Avenue House DS0000064388.V279796.R01.S.doc Version 5.1 Page 12 recording need further improvement. The senior carers stated that in consultation with the Registered Manager, they will review and update all the service users’ care plans by the end of February 2006. It was evidenced that the home ensures that the detailed nutritional screening is undertaken, including weight gain and loss records and appropriate action is taken if required. The home also maintains records of all health checks. The case tracking demonstrated an effective review process together with the home’s ability to meet the changing needs as they occur. The service users health is closely monitored and appropriate medical care services are as and when required. The Inspector spoke to ten service users, who were able to have meaningful conversation. Generally the service users appeared to be content, comfortable and happy. It was evidenced from the staff training records and discussion with the senior carers that three senior carers and several carers have received their training in safe handling of medication. The senior carers stated that the remaining carers are also being enrolled to undertake this mode of training shortly. However, it is the home’s policy that only the senior members of staff would be responsible for handling of and administration of medication to service users. Avenue House DS0000064388.V279796.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 14 and 15 Avenue House – care home provides a good standard of care and promotes individual lifestyles for the service users in residence. The service users are positively helped to exercise choice and control over their lives as far as practicable and safe to do so. Meals at Avenue House are of a good homely type offering both choice and variety and catering for special needs. EVIDENCE: It was seen that the home provides an activities programme in accordance with the service users’ choices, preferences and capacities in relation to – social and leisure activities and cultural interests. It was noted that the home organise entertainment delivered by external entertainers. The records of activities enjoyed by the service users are being appropriately maintained. However, the staff will be asked to record all the activities provided and these activities appropriately incorporated into all individual service users’ care plans. The senior carers stated that the home helps the service users to exercise choice and control over their lives as far as possible and practicable. It was evidenced that the home provided a varied, wholesome and nutritious diet. The meals provided during lunchtime on the day of inspection were well received by the service users. It was observed that those service users, who Avenue House DS0000064388.V279796.R01.S.doc Version 5.1 Page 14 needed assistance in feeding, members of staff were available to assist those service users. The senior carers stated that the menu is changed on a regular basis and in consultation with the service users. Several service users told the Inspector that the food was nice, tasty and well prepared. The kitchen is well equipped, kept clean and tidy. The cook is trained in food safety and hygiene matters. However, it was noted that on the day of inspection the member of staff, who was preparing/cooking evening tea is not trained in food safety and food hygiene matters. The Registered Provider must ensure that any member of staff, who is expected to undertake catering duties in the kitchen must have received training in food safety, food hygiene and infection control. Avenue House DS0000064388.V279796.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 and 18 Concerns and complaints are dealt with promptly and professionally. The service users’ rights are promoted and protected. The service users are protected from abuse by the home’ policies and procedures. The arrangements for the protection of service users from abuse are satisfactory. EVIDENCE: The home has good complaints procedure in place, which is referred to for information in the home’s Service Users’ Guide and in the Statement of Purpose for the home. There is a system of recording concerns and complaints. However, it was noted there had not been any complaints in the home since the last inspection and none had been directed to the Commission for Social Care Inspection (CSCI). The service users spoken to by the Inspector stated that their views and comments are always listened to by the Manager and the senior carers. The senior carers stated that as far as possible, the service users’ legal rights are promoted and protected appropriately. Where the service users are not able to make certain decisions, then their relatives and/or representatives are requested to assist, and where appropriate, the local Advocacy Service is also requested to help. The service users are positively assisted to take part in elections and they use their voting rights. The home has good policy and procedure in place in regard to protection of service users from all forms of abuse. The senior carers stated that the staff Avenue House DS0000064388.V279796.R01.S.doc Version 5.1 Page 16 have been made aware of the adult protection issues through induction training and supervision arrangements. However, the Registered Provider should consider providing professional training on adult abuse and protection issues. Avenue House DS0000064388.V279796.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24, 25 and 26 The general standard of the environment is good providing service users with a comfortable and secure place to live. The standard of cleanliness reflects the ongoing cleaning schedule, which maintains the standard throughout the home. EVIDENCE: The home offers a comfortable and well-maintained environment to all service users. The home has ample communal space – two lounges and a dining room. The home has a rolling programme of redecoration to maintain good standard. The garden and patio areas are also well maintained. The exterior of the building and the canopy have been repainted. However, the gutters are still in need of second/final coat of paint. The old and worn out carpet in the staff room in the main part of the home must be replaced. All the outstanding requirements/recommendations contained in the recent inspection reports of the Fire Safety Officer and the Environmental Health Officer have been appropriately implemented. Avenue House DS0000064388.V279796.R01.S.doc Version 5.1 Page 18 There is good standard of furniture and fittings provided in the service users’ bedrooms. It was noted that the bedrooms have been “personalised” by the service users. However, the excessive noise still could be heard in bedroom 9 from the washing machine/dryer in the laundry next door and/or central heating system, which must be totally eliminated by providing effective soundproof insulation so that the service user have noise free and comfortable bedroom at all times. Portable electrical heaters must be removed with immediate effect from bedrooms 1 and 5 for the safety of service users currently occupying these bedrooms. The hot water temperature was tested in all hot water outlets during the inspection and it was noted that the temperature varied from 14 Degrees C and 52 Degrees C in most of the bedrooms and sinks in the bathrooms/showers and WCs. It was also noted that there were no hot water supply in the sink in the bathroom and there was very low pressure of hot water supply in the second bathroom on the second floor. It was also noted that there was no cold water supply to the sink in the bathroom/WC in the staff training room/Registered Manager and Provider’s office. The hot water in this facility is so hot (i.e. 79 Degrees C) that it could scold any user and thus this issue need to be rectified as a matter of priority. The broken tap to the sink in this bathroom/WC must also be replaced urgently. The senior carers contacted the Registered Provider on the day of inspection and he asked the senior staff to call out the plumber to rectify the hot water supply throughout the home. The Commission received written letter dated 26 January 2006 from Avenue House, which confirmed that the hot water supply at the required temperature level of close to 43 Degrees C has been restored. The portable electric heaters in two bedrooms have been removed. During the inspection, the home was found to be clean, tidy and free from any unpleasant odours. The home has good policies and procedures regarding infection control. It was evidenced from the staff training records that six members of staff have received their training in infection control and other staff also to receive this mode of training shortly. Avenue House DS0000064388.V279796.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, and 30 The home is now adequately staffed at all times, which ensures the quality of care provided, and the ability of the home to meet the needs of service users with varying degrees of dependency levels and differing needs. The home continues to support staff to complete training. The home has good staff recruitment policies and procedures. EVIDENCE: The information provided by the senior carers and the available staff rotas showed that the home in now adequately staffed to care for 20 currently accommodated service users with varying degrees of dependency levels and needs. However, it was noted that the care staff are undertaking domestic, and laundry duties in addition to their caring duties at the weekends, and also catering duties in the evenings throughout the week. These practices are NOT acceptable to the CSCI. The Registered Provider must take urgent and appropriate action to ensure there is adequate domestic and laundry cover provided at the weekends, and cook cover during the evenings and carers must be left to do their caring duties at all times. If the carers are covering the above duties then additional carers must be provided to cover their caring duties. The Registered Provider and the Registered Manager are reminded that the required staffing levels in the home is already a condition of registration and thus the Registered Avenue House DS0000064388.V279796.R01.S.doc Version 5.1 Page 20 Provider and the Registered Manager must take urgent and appropriate action to comply with this requirement as a matter of priority. It was evidenced from the training records that 12 members of staff have completed their NVQ Level 2 training. There are four carers currently undertaking their NVQ Level 2 training and the remaining carers will be enrolled to undertake this mode of training shortly. It was evidenced that the majority of the staff have completed their safe working practice topics training and those who as yet have not received this mode of training must do so as a matter of priority. (See NMS OP38 below). The senior carers stated that the home has now implemented the Care for Skills Council’s (former TOPSS) Induction and Foundation training for all new members of staff. It was noted that the home’s training programme ins now being implemented. The Registered Provider should consider providing specialist staff training in Dementia care, adult protection from all forms of abuse and disability awareness. Avenue House DS0000064388.V279796.R01.S.doc Version 5.1 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 35 and 38 The home has good systems of communication in place to seek views of the service users, their families/friends and other stakeholders. However, in the absence of the Registered Manager, the senior carers were not able to locate any updated information on this matter. Money is well managed on behalf of the service users by the Registered Manager. Health, safety and welfare of the service users and staff are promoted by safe working systems put in place by the Registered Manager and the Registered Provider. EVIDENCE: The senior carers could not find any information on the home’s Quality Assurance development plan and quality monitoring systems. There is already Avenue House DS0000064388.V279796.R01.S.doc Version 5.1 Page 22 a requirement outstanding from the last inspection dated 4 August 2005 on this matter. The Registered Provider and the Registered Manager must take appropriate action to ensure this Standard is fully implemented as a matter of priority. The home assists 12 service users with their monies. A sample of three service users’ money was checked and found to be satisfactory. Accidents and fire prevention records were thoroughly examined, which were found to be satisfactory. All matters pertaining to fire safety and environmental health were found to be satisfactory. However, the Registered Provider must ensure that temperature in ALL hot water outlets must be maintained at all times at the required level of close to 43 Degrees C. The hot water temperature in all hot water outlets must be tested thoroughly on a weekly basis and identified problems must be rectified immediately and appropriate test records maintained at all times. The annual service of gas boiler/central heating system, which was previously carried out on 6 January 2005 is now overdue and must be undertaken as a matter of priority. Those members of staff, who as yet have not received training in safe working practice topics must do so as a matter of priority. (See NMS OP30 above). Avenue House DS0000064388.V279796.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 2 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 X X X X 2 1 3 STAFFING Standard No Score 27 2 28 3 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 1 X 3 X X 2 Avenue House DS0000064388.V279796.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP19 Regulation 23 Requirement The Registered Provider must ensure that the gutters over the canopy are repainted; and that the old and worn carpet in the staff room in the main part of the home must be replaced. The Registered Provider must ensure that the excessive noise heard in bedroom 9 on the ground floor from the washing machine/dryer in the laundry next door and/or central heating system must be completely eliminated by providing suitable sound - proofing insulation so that the service user has a noise free and comfortable bedroom at all times. The portable electric heaters in bedrooms 1 and 5 must be removed in the interest of safety of the service users. The Registered Provider must ensure that the hot water supply to all hot water outlets in the home must be maintained at the required temperature level i.e. close to 43 Degrees C at all times; and that cold water supply is made available to the sink in the bathroom/WC in the DS0000064388.V279796.R01.S.doc Timescale for action 30/04/06 2. OP24 16 & 23 07/02/06 3. OP25 13 30/04/06 Avenue House Version 5.1 Page 25 4. OP27 18 5. OP3 13 &14 6. OP30 12, 13 & 18 7. OP33 24 8. OP38 4, 12, 13, & 23 staff training room and Managers office, and the hot water tap in this facility must also be fitted with a suitable thermostatically controlled mixer valve, and a thermostat is also fitted to the hot water tap to the sink in the staff training room/manager’s office. The Registered Provider must ensure that adequate domestic and laundry cover is provided for at the weekends; and adequate evening cook cover must also be provided for throughout the week, and the carers must be left to do their caring duties. If the carers are asked to provide cover for the above duties then carers replacement must be provided. The Registered Manager must ensure that all the service users’ needs and risk assessments are updated by using a suitable recording format as a matter of priority. The Registered Provider must ensure that all those members of staff who as yet have not received training in safe working practice topics must do so as a matter of priority. (See NMS OP38 below). The Registered Provider must ensure that the homes annual Quality Assurance development plan is fully implemented as a matter of priority. The Registered Provider must ensure that all those members of staff who as yet have NOT received training in safe working practice topics must do so as a matter of priority. The annual service on the gas boiler/central heating system, which was overdue for three weeks must be DS0000064388.V279796.R01.S.doc 04/02/06 20/03/06 31/03/06 28/02/06 31/03/06 Avenue House Version 5.1 Page 26 9 OP7 13 &15 10 OP15 14 &18 carried out as a matter of priority and a copy of the certificate must be made available in the care home and to the CSCI. The Registered Manager must ensure that all the service users’ care plans are reviewed and updated, and the quality and detailed daily care (day and night) records of the care services received by the service users are appropriately recorded by the care staff as a matter of priority. The Registered Manager must ensure that any member of staff on duty in the kitchen involved in preparing, cooking and serving the food to service users must have received training in food safety and food hygiene at all times. 28/03/06 18/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP9 OP18 OP28 Good Practice Recommendations The Registered Provider should continue to support those members of staff who as yet not completed their training in safe handling of medication. The Registered Provider should consider providing staff specialist training in Dementia care, Disability Awareness, and adult protection from abuse. The Registered Provider should continue to support those members of staff who as yet not completed their NVQ Level 2 training. Avenue House DS0000064388.V279796.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Wolverhampton Area Office 2nd Floor St. Davids Court Union Street Wolverhampton WV1 3JE National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Avenue House DS0000064388.V279796.R01.S.doc Version 5.1 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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