CARE HOMES FOR OLDER PEOPLE
Averill House Averill Street Newton Heath Manchester M40 1PD Lead Inspector
Geraldine Blow Unannounced 31 August 2005 09:30 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 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. Averill House F55 F05 s21631 averill house v245038 310805 stage 4. doc.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Averill House Address Averill Street Newton Heath Manchester M40 1PD 0161 688 6690 0161 688 6602 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Southern Cross Healthcare Responsible Individual - Mr Philip Scott CRH Care home N Care home with nursing 48 Category(ies) of DE(E) Dementia - over 65 registration, with number MD Mental disorder of places Averill House F55 F05 s21631 averill house v245038 310805 stage 4. doc.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The maximum number of service users requiring nursing care shall be 46. 2. The maximum number of service users requiring personal care only shall be 2. 3. All service users shall require care by reason of mental disorder (excluding learning disability) or dementia and shall be above 60 years of age. 4. Minimum nursing staffing levels specified in the Notice served in accordance with Section 25(3) of the Registered Homes Act 1984 on 3 June 2001 must be maintained. Date of last inspection 15 December 2004 Brief Description of the Service: Averill House Nursing Home provides accommodation, with nursing care, for a maximum of 48 older people. The home is able to accommodate 45 residents assessed as requiring nursing care and 3 residents assessed as requiring personal care only. All residents had been assessed as having mental health needs. The premises are owned by Nursing Home Properties (NHP) PLC and are leased to Southern Cross Healthcare Limited. Mr Philip Scott is the Responsible Individual on behalf of Southern Cross. The home is situated in the Newton Heath area of Manchester close to a local market, shops, public houses, a park and other social areas and amenities. The home was first registered with the National Care Standards Commission, now the Commission for Social Care Inspection (CSCI), on 30th July 2002 and consistes of a large purpose built home set in its own grounds, which was shared by its sister home operating on the same site. The home offered accommodation in 48 single, en-suite bedrooms. Accommodation for residents is provided on two floors accessed via a passenger lift and stairways. Each floor offers 2 lounges and one dinning room.
Averill House F55 F05 s21631 averill house v245038 310805 stage 4. doc.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection, which was unannounced, was carried out by 2 inspectors and took place over the course of 6 ½ hours on Wednesday 31st August 2005. During the course of the inspection time was spent talking to the operations manager, the manager, residents, relatives and several members of staff to find out their views of the home. Because of the problems the residents have making themselves understood it was difficult to find out what the residents really thought of the home by talking to them. Because of this extra time was spent watching how staff support and interact with residents. Time was spent examining records, documents, resident and staff files. A tour of the building was also conducted. Since the last inspection, in December 2004, the CSCI has received one compliant, which was not upheld. The home kept a record of any complaints made directly to them, which included details of the investigation and any action taken. The requirements from the previous inspection had been addressed and there was evidence that the newly appointed manager was working hard to develop the service. During this inspection only a selection of the key National Minimum Standards were assessed therefore in order to gain the full picture of how the home meets the needs of residents this report should be read with the previous and any future reports. What the service does well:
The atmosphere in the home felt warm and welcoming. Staff were seen to have a good relationship with the residents and a lot of laughter was heard from the staff and residents. Staff were seen to be kind and patient when dealing with residents individual needs. The staff spoken to said that residents privacy and dignity is protected and residents get choice with regard to their daily lives. Unless it is detrimental to their care the residents can go to bed and get up when they choose. One resident said “the staff will take you out if you ask them”. The home has a large enclosed garden for the residents to use and this included a shaded seating area.
Averill House F55 F05 s21631 averill house v245038 310805 stage 4. doc.doc Version 1.40 Page 6 Equipment necessary for the prevention or treatment of pressure sores was viewed during the inspection. The standard of cleanliness throughout the home was high and there were no offensive odours. One resident said, “I have a nice clean room clean”. All of the bedrooms were single occupancy with en-suite facilities. Each bedroom had a suitable privacy lock fitted and all rooms had a lockable storage space. The bedrooms seen were nicely decorated and several had been personalised with resident’s belongings. The home has a daily menu on display in the main reception area and each dining room has a menu sheet available. The menu offers a choice at each mealtime and staff spoken to said alternatives to the set menu are available, for example a sandwich or cheese on toast. This was seen to happen during the inspection. A couple of residents did not want what was on the menu and sandwiches were seen given to those residents. One resident said, “the food is nice and you get a choice of what to eat”. The complaint policy was on display in the main reception area and included all the correct information. The manager said that the complaint procedure is also included in the Service User’s Guide and all residents have been given a copy. What has improved since the last inspection?
A new manager has been appointed to the home. He is a qualified Registered Mental Nurse (RMN) and has attended an interview with the Commission for Social Care Inspection for registration. He started work at the home at the end of March 2005. He has a lot of nursing experience and seems very keen to improve standards within the home for the residents. In an effort to create a more homely atmosphere the manager has put new pictures along the corridor. Some of these include framed newspapers with interesting articles from an age appropriate time. The manager has also bought individual nameplates, a doorknocker and a letterbox for all the residents’ bedroom doors in an attempt to individualise the rooms. The home employs 2 activities co-ordinators, although 1 is on maternity leave. The manager said that activities are an area he is keen to develop. This was confirmed by the activity co-ordinator. She said that the manager had spent time with her developing the role and she feels that the activities have improved since the new manager has taken over. A summer fair had been held at the home the weekend prior to the inspection and on the day of the unannounced inspection the home was holding a lunch club, where relatives and friends had been invited to join the residents for their midday meal. Also
Averill House F55 F05 s21631 averill house v245038 310805 stage 4. doc.doc Version 1.40 Page 7 some of the residents had made cakes that morning to be eaten with afternoon tea. Since the last inspection 3 bedrooms and 1 dining room has been redecorated 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.
Averill House F55 F05 s21631 averill house v245038 310805 stage 4. doc.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Averill House F55 F05 s21631 averill house v245038 310805 stage 4. doc.doc Version 1.40 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 standard(s) EVIDENCE: None of the Standards in this section were assessed on this occasion. Averill House F55 F05 s21631 averill house v245038 310805 stage 4. doc.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 & 10 Overall the health and personal care needs of the residents appeared to be met at the home. However risk assessment for the use of wheelchair lap belts and the “bucket chair” must be implemented. The system for recording all prescribed medicines needed some improvement to provide an accurate audit trail of medication. EVIDENCE: Residents care plans were not fully assessed during this inspection as the home was in the process of introducing new care plan formats. A thorough inspection of the care plans will be conducted at the next inspection once the new system is fully implemented. However, several care plans were examined as part of the case tracking procedure. On a tour of bedrooms it was noted that one of the residents was sleeping on a mattress on the floor. This had been risk assessed appropriately. However, in conversation with the unit manager it was apparent that night staff were occasionally required to deliver personal care to the resident from a kneeling position on the floor. The care plan did not contain a moving and handling assessment detailing safe practice in back care. Furthermore, it is
Averill House F55 F05 s21631 averill house v245038 310805 stage 4. doc.doc Version 1.40 Page 11 recommended that consideration should be given to providing a suitable rise and fall bed for this residents use. The plans examined demonstrated that risk assessments had been completed and consent obtained for the use of bed rails but not for the use of wheelchair lap belts or the “bucket chair”, which are also considered a form of restraint. On a tour of the building it was noted that protective bumpers accompanied the use of bed rails. The manager said that it was his intention to conduct a regular audit of the care plans to ensure the required standard is maintained. All residents were registered with local General Practitioners and had access to visiting healthcare professionals e.g., Dietician, Chiropody, Dentistry and Ophthalmology. Equipment necessary for the promotion of tissue viability and the prevention or treatment of pressure sores was viewed during the inspection. The home had a comprehensive corporate medication policy. Both drug trolleys were stored in the nurses’ office, which was kept locked when not in use. Both trolleys were secured to the wall. The home a blister pack system and each tablet/capsule was sealed into a separate compartment for easy identification. The drug fridge was situated within the nurses’ office, which was kept locked when not in use and daily temperatures had been recorded. The home appeared to operate a safe system for receipt, storage, and administration of medication. Inline with new legislation, from the 1st Aril 2005, the home employed the services of an independent company to dispose of pharmaceutical waste. A current list of staff signatures was available. The medication file contained residents’ photographs, which acted as an aid to identification at the time of medication administration. In addition the file contained a list of staff signatures. The home does not see the prescriptions before they are dispensed, nor do they have a copy of the prescriptions to use as an up to date copy of each service users medication. Professional guidelines indicate that the home should see the prescriptions prior to dispensing and good practice indicates a copy of the prescription should be kept of these prescriptions. The manager confirmed to the inspector that he had contacted the dispensing pharmacy to discuss the above issue. One staff member spoken to said that she did accept a verbal order to change medication, by a General Practitioner, if checked by another of staff. These
Averill House F55 F05 s21631 averill house v245038 310805 stage 4. doc.doc Version 1.40 Page 12 changes must only be accepted if written confirmation is received for example in the form of a fax. During the course of the inspection the manager obtained a copy of Royal Pharmaceutical Guidelines for reference. One of the inspectors had lunch with the residents. The administration of medication was observed during the meal. It was noted that on one occasion a resident’s medication was added to a spoonful of food as the resident was eating. This practice had not been included in the individual care plan. It was explained to the inspectors that the particular resident did not like taking tablets but preferred liquid medication. The manager assured the inspector that he would consult with the general practitioner for advice and guidance on the most appropriate method of medication administration to this individual and ensure that the agreed method is clearly detailed in the care plan. From observations and discussions with staff members it appeared that residents privacy and dignity was respected. However during the midday meal a member of staff was overheard to say, ‘Good boy’ to one of the residents. This language is inappropriate and patronising in the presence of older people. Averill House F55 F05 s21631 averill house v245038 310805 stage 4. doc.doc Version 1.40 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 standard(s) 12 & 15 Activities were available to residents. Meals appeared to be nutritious and well balanced. However, the presentation needed some improvement. EVIDENCE: Throughout the inspection it was noted that staff had a good rapport with residents. Staff were observed to engage in meaningful conversation with residents and share jokes and stories. It was evident that significant progress had been made in the provision of appropriate activities for residents. One of the homes activities co-ordinators explained the process for assessing the social needs of residents. A summer fair had been held at the home the weekend prior to the inspection and residents care plans detailed the outcome of a variety of activities engaged in by residents. A poster was also seen advertising a trip to the Imperial War Museum. On the day of inspection the home was holding a lunch club and residents relatives and friends had been invited to join the residents for their midday meal. The daughter of one of the residents told the inspector that in her opinion not enough activities were being provided. It was recommended that the home further develop communication with relatives by discussing the type and frequency of activities. Averill House F55 F05 s21631 averill house v245038 310805 stage 4. doc.doc Version 1.40 Page 14 The home provided an attractive dinning room on each floor and most residents were encouraged to have their meals there. However residents were able to use other areas of the home on request. A menu is on display in the main reception and in each dining room. The menus inspected had been developed on a 4-week rota system. The meals offered appeared nutritious and wholesome. One of the inspectors sat with the residents at lunchtime. This was not the main meal of the day. Residents had a choice of two snack meals or an alternative snack on request. The inspector was served chicken and mushroom pie and peas. Although adequate as a snack meal the food was not very attractively presented and the inspector was not given the option of having gravy with the meal. Some of the residents would not be able to request gravy so staff should ensure that each individual is given that choice. Additionally, a piece of silver foil was accidentally served with the inspector’s meal. This could potentially be a choking hazard to a frail resident with swallowing difficulties. It was recommended that the registered manager occasionally joins residents for a meal so that the quality of catering provision can be monitored. Throughout the meal staff were responsive to individual resident’s needs for assistance. The kitchen and food storage areas were examined during the inspection. Food stocks had been appropriately date labelled and fridge and freezer temperatures were being recorded on a daily basis. A packet of pastry mix in the dried food store had been opened and not re-sealed after use. The manager confirmed to the inspector that he had ordered some airtight box’s to store opened dried food to address this problem. The kitchen and storage areas were generally clean and hygienic. However, the kitchen ceiling needed to be cleaned and cracks and flaking plaster must be repaired to prevent contamination in food preparation areas. In discussion with the cook it was noted that several soft diets were prepared for residents using one food blender. Consequently it was recommended that a further food blender be provided. The manager confirmed that he was looking into purchasing a new blender. Averill House F55 F05 s21631 averill house v245038 310805 stage 4. doc.doc Version 1.40 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 standard(s) 16 & 18 The complaints procedure was on display in the main reception area. The home must ensure that the policies and procedures that serve to protect the residents from abuse are always accessible within the home. EVIDENCE: The home had the complaint procedure on display in the main reception area and was included in the Service User’s Guide which every resident had been given a copy of. Since the last inspection the home received 6 complaints, 2 of which had been upheld. The home maintained a complaint file, which contained details of the complaint, the actions taken and the outcomes. The home had a comprehensive file regarding Protection of Vulnerable Adults Guidance (POVA) and the manager told the inspectors that the home had corporate policies relevant to POVA including whistle blowing. However on the day of inspection the policy for the protection of vulnerable adults could not be found by the manager or by the staff on one of the units. The manager told the inspectors that all staff had received informal training on the actions to be taken in the event of an allegation of abuse and was in the process of organising formal training. However one member of staff spoken to said that she had not received any training. During the course of the inspection the manager obtained copies of the Department of Health (DOH) “No Secrets” Guidance and the Manchester MultiAgency Vulnerable Adult Protection Policy. Averill House F55 F05 s21631 averill house v245038 310805 stage 4. doc.doc Version 1.40 Page 16 The home had a policy precluding staff from accepting gifts or being involved in the making of or benefiting from residents wills. Averill House F55 F05 s21631 averill house v245038 310805 stage 4. doc.doc Version 1.40 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 standard(s) 19, 21, 24 & 26 The homes environment was generally clean, comfortable and equipped to meet the needs of the residents. However some areas had been identified as requiring re-decoration. There were some concerns relating to infection control to protect residents wellbeing. EVIDENCE: The inspectors undertook a tour of the premises along with the handyperson and unit managers. The handyperson had specific responsibility for environmental health and safety and records held provided evidence that regular safety checks and maintenance were being undertaken. All bedrooms had en-suite toilets and wash hand basins. A sample of hot water temperatures were taken and these were found to be around the recommended temperature of 43 degrees Celsius. In addition the handyperson had records of weekly water temperature testing. An enclosed garden was provided for residents use and this included a shaded seating area. A requirement was made for weeds to be cleared from the flagged patio area, as this is potentially a tripping hazard.
Averill House F55 F05 s21631 averill house v245038 310805 stage 4. doc.doc Version 1.40 Page 18 Minor shortfalls were noted. The waste bin in one of the communal toilets had the lid missing and a wardrobe in bedroom 69 had a door handle missing. The handyperson stated that these issues would be identified and addressed during his weekly health and safety audits. The home had adequate bathing facilities and these along with communal WC’s were clearly marked. The doors to the sluice areas had electronic digital locks, which were keypad operated. These were kept locked when not in use. The home had corporate policies relating to infection and the laundry was sited on the second floor of the home, which did not offer any resident accommodation. The laundry was found to be clean and well organised. The home has had a recent outbreak of scabies and a number of concerns relating to infection control were identified during the inspection. It was noted that the hoists were generally dirty and were not being cleaned in-between resident use. These must be thoroughly cleaned. It has been recommended, in accordance with infection control guidance that: 1. Persona Protective Equipment (PPE), which includes gloves, aprons and wipes should be made available in residents’ bedrooms, toilets and bathrooms to facilitate the management of personal care. 2. The home should consider purchasing individual hand held alcohol gel for staff. 3. The home should ensure equipment is cleaned in between resident use. 4. The home should make equipment wipes available in the nurses’ office, sluices and next to hoists to facilitate cleaning. 5. To prevent the risk of cross infection an individual sling should be provided for each resident requiring the use of the hoist. 6.The home should develop and implement a policy on the use of wipes. During the inspection the manager attempted to contact the infection control nurse for up to date legislation and professional guidance regarding the above recommendations. Training must be arranged for himself and the unit managers. Averill House F55 F05 s21631 averill house v245038 310805 stage 4. doc.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28 & 29 The numbers and skill mix of staff appeared to be sufficient to meet the needs of the residents. The homes recruitment policies and procedures appeared to promote the safety and wellbeing of the residents. However the authenticity of all references must be checked. EVIDENCE: At the time of the inspection the home accommodated 46 residents i.e. 44 residents assessed as requiring nursing care and 2 residents assessed as requiring personal care only. The numbers and skill mix of the staff, at the time of inspection, appeared to be sufficient to meet the needs of the number of residents accommodated. In conversation with the inspector two carers stated that they had undertaken training in health and safety, including fire procedures and were also working towards NVQ level 2 in care. The care home employed 22 care staff. Two members of care staff have achieved NVQ 2 and a further 6 have commenced training. The sample of staff files inspected contained all the information and documents listed in Schedule 2 of the Care Home Regulations 2001. However it was noted that the authenticity of the last employer’s reference, in one file, had not been checked. The manager attempted to action this during the course of the inspection. Evidence was seen of Criminal Record Bureau (CRB), Protection of Vulnerable Adult (POVA) and Personal Identification Number (PIN) checks.
Averill House F55 F05 s21631 averill house v245038 310805 stage 4. doc.doc Version 1.40 Page 20 The manager said that all staff had been given a copy of the Code of Practice set by the General Social Care Council Averill House F55 F05 s21631 averill house v245038 310805 stage 4. doc.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 & 36 The home is well managed by a qualified and competent manager. Staff appear to be appropriately supervised. EVIDENCE: The manager is a Registered Mental Nurse (RMN) and has attended interview with the Commission for Social Care Inspection for registration. He has the responsibility of managing Averill House and no other home. He has not yet commenced the Registered Manager’s Award. Evidence was seen of staff supervision. Since the manager took up post at the end of March 2005 all staff have had at least 1 supervision session and some staff have had 2 or 3 sessions. Averill House F55 F05 s21631 averill house v245038 310805 stage 4. doc.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 2
COMPLAINTS AND PROTECTION 2 x 3 x x 3 x 2 STAFFING Standard No Score 27 3 28 3 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 3 x x x x 3 x x Averill House F55 F05 s21631 averill house v245038 310805 stage 4. doc.doc Version 1.40 Page 23 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. 1. Standard 7 Regulation 13 Requirement A moving and handling risk assessment must be implemented detailing safe practice in back care for staff to use when delivering personal care to the resident who sleeps on a mattress on the floor. The use of restraints such as wheelchair lap belts and the Bucket Chair must be risk assessed and consent be obtained for its use. 1. Prescriptions must be seen and checked prior to sending them to the pharmacy. Timescale for action 30/9/05 2. 7 13 30/9/05 3. 9 13 Before next medicines are dispensed 4. 9 13 5. 10 12 6. 15 13 2. An up to date record of service users medication must be maintained by the home Verbal orders given to home 30/9/05 staff by a General Practitioner to change medication must only be accepted by written confirmation. To ensure that residents dignity 30/9/05 is protected at all times staff must not use inappropriate and patronising language. The responsible individual must 10/10/05 ensure the kitchen ceiling is cleaned and the cracks and
F55 F05 s21631 averill house v245038 310805 stage 4. doc.doc Version 1.40 Page 24 Averill House flaking plaster must be repaired to prevent contamination in the food preparation area. 7. 18 12 1. The homes policy for the Protection of Vulnerable Adults must be accessible at all times. 2.All staff must be made aware of the action to be taken in the event of an allegation of abuse. The weeds must be cleared from the flagged patio area, as this is potentially a tripping hazard. With particular reference to the recent outbreak of scabies the responsible individual must ensure that: 1. The home manager seeks advice from the infection control nurse for up to date legislation and professional guidence. 3. Infection control training must be arranaged for the manager and unit managers. 2. All hoists must be thoroughly cleaned to prevent the risk of cross infection. 3.All waste bins must have a lid in situ. 10. 11. 29 19 The responsible individual must ensure the authenticity of references are checked prior to the work commencing. The manager must commence NVQ level 4 in management and care or its equilivant. 30/9/05 1/11/05 8. 9. 19 26 13 13 30/9/05 30/9/05 12. 31 9 31/12/05 Averill House F55 F05 s21631 averill house v245038 310805 stage 4. doc.doc Version 1.40 Page 25 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 7 12 15 Good Practice Recommendations It is recommended that the responsible individual gives consideration to providing a suitable rise and fall bed for the resident who is speeping on a matress on the floor. It is recommended that the home improve communicatin with relatives by discussing the type and frequency of activities. 1. The responsible individual should ensure that all residents are given a choice of accompaniments with their meal e.g. gravy. 2. It was recommended that the registered manager occasionally joins residents for a meal so that the quality of catering provision can be monitored. Due to the recent outbreak of scabies it is recommended that: 1. Personal Protective Equipment (PPE), which includes gloves, aprons and wipes should be made available in residents’ bedrooms, toilets and bathrooms to facilitate the management of personal care. 2. The home should ensure equipment is cleaned in between each resident use. 3. The home should make equipment wipes available in the nurses room, sluices and next to hoists. 4. To prevent the risk of cross infection an individual sling should be provided for each resident requiring the use of the hoist. 5. The home should consider purchasing individual hand held alcohol gel for staff. 6.The home should develop and implement a policy to include the above The responsible individual should ensure that 50 of care staff are trained to NVQ level 2 by the end of December 2005.
F55 F05 s21631 averill house v245038 310805 stage 4. doc.doc Version 1.40 Page 26 4. 26 5. 28 Averill House Averill House F55 F05 s21631 averill house v245038 310805 stage 4. doc.doc Version 1.40 Page 27 Commission for Social Care Inspection 9th Floor Oakland House Talbot Road Manchester M16 0PQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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