Inspection on 08/10/07 for Averill House

This inspection was carried out on 8th October 2007.

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

Averill House 18/02/09

Averill House 08/10/08

Averill House 29/01/07

Averill House 17/01/06

Averill House 31/08/05

Averill House 15/12/04

Averill House 17/06/04

Averill House 06/01/04

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

CARE HOMES FOR OLDER PEOPLE Averill House Averill Street Newton Heath Manchester M40 1PD Lead Inspector Geraldine Blow Unannounced Inspection 8th October 2007 09:45 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 Averill House DS0000021631.V349151.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Averill House DS0000021631.V349151.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Averill House Address Averill Street Newton Heath Manchester M40 1PD 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) 0161 688 6690 0161 688 6602 www.schealthcare.co.uk Southern Cross Healthcare Services Ltd ****Post Vacant**** Care Home 48 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (48), Mental disorder, excluding learning of places disability or dementia (48), Mental Disorder, excluding learning disability or dementia - over 65 years of age (48) Averill House DS0000021631.V349151.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of residents shall be 48, of whom no more than 46 require nursing care. Residents requiring care by reason of dementia shall be aged 65 years or over with the exception of one named resident. Should this resident no longer reside at the home or their primary need for requiring care change, this place will revert to the category of dementia, over 65 years of age (DE(E)). Residents requiring care by reason of mental disorder, excluding learning disability or dementia, shall be 60 years of age or above with the exception of one named resident, who is currently below this age. 29th January 2007 3. Date of last inspection Brief Description of the Service: Averill House Nursing Home provides accommodation, with nursing care, for a maximum of 48 older people. 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. 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. Averill House is a large purpose built home set in its own grounds. Another home operated by Southern Cross is also on the same site. Registered nurses with both mental health and general nurse qualifications are on duty throughout the 24 hours and a manager who is also a registered nurse manages the home on a day-to-day basis. The home offers 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 dining room. The charges for fees range from £378.84 to £640.00 per week. Averill House DS0000021631.V349151.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report is based on information gathered by the Commission for Social Care Inspection (CSCI) since the last inspection on 29 January 2007 and supporting information received in the Annual Quality Assurance Assessment (AQAA) submitted by the manager prior to this visit. Residents, staff and General Practitioners (GP’s) were sent comment cards. Five resident comment cards, filled in with the help of relatives and 4 staff comment cards were received. No GP comment cards were received by CSCI. This unannounced visit forms part of the overall inspection process and took place on Monday 8 October 2007. The opportunity was taken to look at all the core standards of the National Minimum Standards (NMS). This inspection was also used to decide how often the home needs to be visited to make sure that it meets the required standards. As part of the visit time was spent examining relevant documents and files, talking with the home’s manager, several people living at the home and some members of staff. A tour of the building was undertaken. What the service does well: Details about the service provided at Averill House in the form of a Service User Guide and a Statement of Purpose are up to date and available to prospective residents and/or their relatives. All new residents are given a Service User Guide on admission to the home and a Statement of Purpose is available in the main reception and a copy can be provided on request. A pre admission assessment of needs continues to be carried out before a resident is admitted to the home to make sure that their needs can be met. Visits to the home by prospective residents and/or their relatives are encouraged before a decision about admission is made. The atmosphere in the home felt comfortable and relaxed. Residents were seen to be appropriately and nicely dressed. The staff were kind and caring in their approach to residents and residents were seen to be freely walking around the home. There is an open visiting policy, which was confirmed by the staff spoken to. Systems were in place to support residents or visitors to make a complaint and the majority of returned residents comment cards, stated that they knew how to make a complaint. Averill House DS0000021631.V349151.R01.S.doc Version 5.2 Page 6 Policies and procedures were in place to protect residents from abuse and staff were receiving appropriate awareness training. Staff are encouraged and supported to undertake training to ensure that they have the necessary skills to meet the needs of the residents living at the home. There are good recruitment procedures to ensure that the staff employed are safe to work with residents. The manager had been in post since May 2007 and had a good knowledge of the residents individual care needs and demonstrated a commitment to improve standards within the home. During the visit he stopped and talked to the residents he passed and was sensitive to their individual needs. What has improved since the last inspection? What they could do better: A pre admission assessment of needs is carried out before a resident is admitted to the home to make sure that the home can meet their needs. However it is recommended that the assessment include an assessment of any specific religious and cultural needs. The systems for medication administration needs some improvements to ensure that residents receive medication as prescribed by the GP. In order to make sure that residents receive the care they need their individual plans of care must be updated to reflect any change in their care needs. Averill House DS0000021631.V349151.R01.S.doc Version 5.2 Page 7 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. Averill House DS0000021631.V349151.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Averill House DS0000021631.V349151.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 & 3 (Standard 6 intermediate care is not provided at Averill House). Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service Prospective residents are given sufficient information to make a decision about where to live and prospective residents needs are assessed prior to them being admitted to the home to ensure that their needs can be met. EVIDENCE: The Statement of Purpose is available to any person to access in the main reception area and a copy can be provided on request. The Service User Guide is given to all newly admitted residents. Where possible, prospective residents and their family/representative are encouraged to view the home prior to making a decision about admission. A pre admission assessment form is in use to ensure that prospective residents are only admitted on the basis of a full assessment and for those residents who are referred through Care Management arrangements a copy of the Care Management Assessment is obtained before admission is arranged. However it was noted that the pre admission assessment did not include an assessment of Averill House DS0000021631.V349151.R01.S.doc Version 5.2 Page 10 any specific religious and cultural needs. This information is necessary to ensure that issues around diversity and equality are identified and responded to in a person centred approach. A recommendation has been made to address this. Averill House does not provide an intermediate care service. Averill House DS0000021631.V349151.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service Some shortfalls were identified in ensuring that the health care needs of residents were being met. EVIDENCE: Four residents were case tracked during this inspection visit and their care files were examined. Each resident had an individual plan of care which had been reviewed on a monthly basis. The files were found to be user friendly and easy to use. Some areas of the care plans were not person centred and were quite vague and did not clearly set out the personal preferences of residents or the individual actions which needed to be taken by staff to ensure that residents’ individual health and personal care needs are fully met. For example some entries included “assist with washing and dressing and offer a shower at least once a week” and “needs assistance with personal hygiene” yet there were no details of what assistance was needed. One care plan identified that the Averill House DS0000021631.V349151.R01.S.doc Version 5.2 Page 12 resident has “agitation and aggression ” yet the plan of care did not contain any details of how staff should manage this behaviour. To ensure that residents’ care needs are appropriately met the plans of care must accurately reflect the identified care need and how that need can be met. It is recommended that that all residents care plans are developed on a person centred approach and contain sufficient detail for staff to meet all residents’ identified needs. Evidence was seen that the care plans had been reviewed on a monthly basis but in some cases the care plan had not been updated accordingly. For example it was of concern that a report from the Speech and Language Therapist (SALT), dated April 2007, detailed that the resident required drinks thickened to pudding consistency yet the care plan, dated February 2007, had not been updated and detailed that that drinks should be thickened to custard consistency. Also one plan of care had highlighted the dose of insulin required. However the dose had been reduced but the care pan had not been updated to reflect the reduction. These have the potential to put residents at risk. To ensure all residents care needs are appropriately met it is recommended that the care plan is updated as soon as a change of care need is identified. Appropriate risk assessments had been undertaken, which included a risk assessment for the use of bed rails. It was encouraging that evidence was seen that where possible the plan of care had been drawn up with the involvement of the resident/representative. There was a daily information record, however the entries were of varying standards. Some entries contained detailed information and other entries were vague, lacked detail and did not accurately evidence the care given. In order to ensure that all assessed needs of residents are being met it is recommended that an accurate record of care provided should be kept. Residents were registered with a General Practitioner and evidence was seen of referral to other specialised services according to individual assessed needs, for example, Dietician, Speech and Language Therapist and Chiropodists. Medication Administration Record Sheets (MAR) were examined. From the evidence available medication carried over from the previous month had been recorded and deliveries and returns of prescribed medications had been recorded and accounted for so providing a full audit trial. However, it is recommended that 2 staff witness and sign for the disposal of waste medication. Averill House DS0000021631.V349151.R01.S.doc Version 5.2 Page 13 A tablet count was undertaken of medication that was not included in the blister packs. There were no discrepancies found. From a visual check of the blister packs all medication had been given appropriately. It was of particular concern that it was week 3 of a 4 week cycle and for one particular resident the MAR sheet and the prescription instructions on the box of tablets stated give one tablet four times a day, yet it had been signed for on the MAR as being one tablet given twice a day. The nurse said that they were giving one tablet twice a day because the dose had been changed mid cycle last month. However it is not up to the nurses to decide what the prescription dose of medication should be. Medication must be administered against a written prescription and if there is any concerns about the prescription the GP must be contacted without delay for clarification. In addition there is not a copy of the GP’s original prescription so that staff can cross reference the medication received from the dispensing pharmacy with the medication prescribed by the GP. A recommendation has been made to address this. It was found that one tablet was prescribed as 1 or 2 up to 4 times a day ‘when required’. There was no explanation as to what ‘when required’ meant. To ensure that residents are not placed at risk there must be sufficient information to enable nurses to administer medication as intended by the General Practitioner (GP) and therefore the doctors’ instructions must be recorded. Several residents are prescribed a thickener, which is used to thicken drinks and soups for residents with swallowing impairment which had been signed for on the MAR sheet. The thickener was being signed for on the MAR by the nurse administering the medication 3/4 times a day. However the nurse and the manager confirmed that the MAR sheet did not accurately reflect the correct number of thickened drinks given and the signature on the MAR was not necessarily the signature of the staff member who would have given the drink to the resident. There was a separate fluid intake-recording sheet. However it was of concern that for the five days of recordings looked at, no drinks had been signed for as being given after 5pm and on all days it was recorded that only 3 drinks had been given to the resident. Either the fluid intake record is inaccurate or the resident is not receiving an adequate supply of fluids. In order to ensure that residents care needs are being met an accurate record should be maintained of each drink / soup etc that has been thickened and any other liquid the residents have had to drink. It is essential that the person making the drink signs a record sheet; this does not have to be the nurse and it does not have to be signed on the MAR sheet. A separate drinks recording sheet may be constructed for each resident and the MAR can cross reference to the recording sheet. Recommendations have been made to address these issues. Averill House DS0000021631.V349151.R01.S.doc Version 5.2 Page 14 From observations made and discussions with a member of staff it appeared that the nurses and care staff did treat the residents with respect and dignity when assisting them. However it was of concern that the Chiropodist was seen attending to a resident while he was sat in a chair on the main corridor and none of the staff challenged this practice. The inspector was informed that this was not the usual Chiropodist and that residents are usually attended to in the privacy of their own room. However this practice does not promote the privacy and dignity of residents and staff should challenge such practice. Averill House DS0000021631.V349151.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service Activities were provided and residents were able to maintain contact with family and friends. EVIDENCE: From the information received in the completed AQAA and from talking to the manager it appeared that activities are high on the agenda for Averill House. Since the last inspection an activity coordinator had been employed and activities are being undertaken and future activities are being planned. The coordinator records who attends which activities and she also records if residents have been offered the opportunity to take part but have declined. She also said that she keeps a record of any discussions with residents or their relatives to obtain information about what activities they would like to do or what their individual interests and hobbies are. Two of the five returned resident comment cards stated that activities usually take place and 3 said that they sometimes take place. One comment received was “There is a new activities person who has made a lot of difference to everyone”. Staff confirmed that the home facilitated open visiting and visitors could be received in the residents’ own room or any of the communal areas of the home. Averill House DS0000021631.V349151.R01.S.doc Version 5.2 Page 16 From observations and speaking to staff it appeared that where possible residents are encouraged to exercise choice and control over their lives and that residents are encouraged to bring personal possessions into the home. As already detailed in this report the ‘nutmeg’ system has recently been implemented and a new menu piloted. An alternative to the main meal is available at each mealtime or any reasonable alternative is available to residents. Staff spoken to confirmed this. Most of the residents spoken to during the this visit said that they had enjoyed the meal they had just eaten, although a few had forgotten what the meal was. Averill House DS0000021631.V349151.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service People are encouraged and supported to raise their concerns and complaints and there are policies, procedures and systems in place to protect residents from abuse. EVIDENCE: There is a complaint procedure, which was on display in the main reception area, and a copy was included in the Service User Guide, which every resident had been given. Three of the returned resident comment cards identified that they knew how to make a complaint. The manager said that he has been in post since May 2007 and has not yet received a complaint. However he was aware of the need to keep detailed records of any complaints made, any investigations, including staff statements, copies of any correspondence and an outcome of the complaint. The manager said, and the competed AQAA confirmed, that he operates an open door policy and residents, relatives/visitors, staff and visiting professionals to the home are encouraged to raise any concerns or complaints with him. There were policies and procedures in relation to the Protection of Vulnerable Adults from Abuse and Whistle Blowing. The home had a copy of the Manchester Multi-Agency Policy on the Protection of Vulnerable Adults from Abuse. The manager had not yet undertaken Safeguarding Adults awareness Averill House DS0000021631.V349151.R01.S.doc Version 5.2 Page 18 training but he could accurately describe the actions to be taken in the event of an allegation of abuse being made. Evidence was seen that training was being provided on an ongoing basis. Averill House DS0000021631.V349151.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The premises are safe and the home’s environment was adequately maintained both internally and externally. EVIDENCE: Since the last inspection visit several bedrooms had been completely refurbished and the corridors were due to be re-painted. There was a stand in the main reception with booklets and leaflets on Dementia and Althemizers for people to read or take away and read. This is seen as good pratice. The corridor carpets were stained and marked in palaces, although these were seen to be spot cleaned during the course of the visit. Generally the home was clean although the inspector had to ask for 2 of the downstairs toilets and the wall in one of the shower rooms to be cleaned. In addition some of the Averill House DS0000021631.V349151.R01.S.doc Version 5.2 Page 20 furniture was showing signs of general wear and tear. The manager said that new bedding was constantly being ordered and new lounge and dining room furniture had been ordered. He confirmed that the internal refurbishment of the home was continuing on an ongoing basis. Two of the returned resident comment cards indicated that the home was always clean, 1 indicated that is was usually clean and 2 of the comment cards indicated that it was sometimes clean. It was noted that there was not any gloves, aprons or wipes (PPE) stored close to the toilets or bathrooms. In an attempt to minimise the risk of cross infection and possible distress to residents it is recommended that PPE are easily accessible to staff should they need them. The standing hoist on the ground floor was seen to be dirty and the manager confirmed that it was not cleaned after each resident had used it. In an attempt to minimise the risk of cross infection and inline with the Department of Health Infection Control Guidance for Care Homes it is recommended that the hoist is surfaced cleaned in between resident use. The garden area was safe, well maintained and accessible to residents. Averill House DS0000021631.V349151.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The number and deployment of staff appeared sufficient to meet the residents’ assessed needs and the procedures for recruiting staff were robust and provided adequate safeguards to protect residents. EVIDENCE: At the time of the inspection the home accommodated 44 residents i.e. 42 residents assessed as requiring nursing care and 2 residents assessed as requiring personal care only. The numbers and skill mix of the staff appeared to be sufficient to meet the needs of the number of residents accommodated. The majority of returned resident comment cards indicated that staff were usually available when you needed them. The completed Annual Quality Assurance Assessment (AQAA) detailed that sixteen care staff are employed, 8 of which had achieved NVQ level 2 or above and 3 members of care staff are currently undertaking the training. The staff files examined contained the appropriate documentation as required by Schedule 2 of The Care Homes Regulations 2001. Staff files contained photocopied documents, for example passports and certificates. However there was no evidence that the original documents had been seen. It is Averill House DS0000021631.V349151.R01.S.doc Version 5.2 Page 22 recommended that that all photocopied documents are signed to indicate that the original had been seen. The NMC website is regularly checked by Southern Cross for nurse suspension or exclusion from the register. These details are sent to the home manager who checks the information. In addition there is a computerised matrix that identifies when PIN numbers are due for renewal. The manager confirmed that all newly recruited members of staff must attend induction training prior to starting work and evidence was seen of this in some of the staff files inspected. There is a structured, corporate induction in place, although the manager confirmed that this has not been updated to take account of Skills for Care and the AQAA completed by the manager prior to this visit confirmed that both parts of the Skills for Care National Minimum dataset for social care have not been completed. Evidence was seen of ongoing staff training and a computerised system ‘Cold Harbour’ identifies when individual staff require training. Averill House DS0000021631.V349151.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems and procedures were in place to safeguard and protect residents’ financial interests and the home was seen to promote the health, safety and welfare of the residents and staff. EVIDENCE: The manager has been in post since May 2007 and is in the process of applying to CSCI for Registration. There is a quality monitoring system to seek feedback from residents and the relatives of the residents who use the service. The administrator is responsible for sending out satisfaction questionnaires on an ongoing basis. The completed Averill House DS0000021631.V349151.R01.S.doc Version 5.2 Page 24 questionnaires are sent directly to the company’s head office where the results are reviewed. However the manager said that the response rate was very low. There is a comment book in the main reception area which is checked daily for comments and there are some questionnaires if people want to fill them in. To ensure that standards are maintained the manager undertakes regular audits, for example a review of pressure ulcers, care plan audits, medication audits, a review of the Regulation 37 reports, a review of any variants in resident’s weights and there are weekly managers meetings. In addition the manager holds 2 monthly resident/relative meetings and minutes are taken. Evidence was seen that the systems in place safe guarded resident’s financial interests. Southern Cross Healthcare Ltd have a national agreement with CSCI’s Provider Relationship Manager (PRM) regarding residents’ finances. Secure facilities were provided for money and valuables held on behalf of residents and receipts are given. The information provided in the AQAA demonstrated that the home’s maintenance certificates and records were up to date. Fire safety checks are carried out, although there was a gap in from week 26 to week 31 when the person responsible for doing the checks went off sick. However this has now been rectified and are regularly being carried out, with the exception of the emergency lighting. The manager confirmed that this test would take place on the 10/10/07. These shortfalls do have the potential to put residents at risk. Averill House DS0000021631.V349151.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 3 Averill House DS0000021631.V349151.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 (1) Requirement To ensure that residents’ care needs are appropriately met the plans of care must accurately reflect the identified care need and how that need can be met. 1. To ensure that residents are not placed at risk there must be sufficient information to enable nurses to administer medication as intended by the General Practitioner (GP) and therefore the doctors’ instructions must be recorded. 2. Medication must be given as prescribed by the GP. (Previous timescale of 19/2/07had not been met and still applies) Timescale for action 05/11/07 2. OP9 13.2 08/10/07 Averill House DS0000021631.V349151.R01.S.doc Version 5.2 Page 27 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 OP3 Good Practice Recommendations To ensure all residents needs can be met it is recommended that the pre- admission assessment include an assessment of any specific religious and cultural needs. 1. It is recommended that all residents care plans are develop on a person centred approach. 2. It is recommended that the care plan is updated as soon as a change of care need is identified. 3. It is recommended that an accurate daily record of the care provided is be kept. 3. OP9 1.It is recommended that the MAR should clearly cross reference to where there is a signed accurate recording of thickened fluids. 2. It is recommended that 2 staff witness and sign for the disposal of waste medication. 3. It is recommended that there is a copy of the GP’s original prescription so that the medication received can be checked against medication prescribed. 4. 5. OP10 OP26 It is recommended that staff challenge other professionals’ practice if resident’s privacy and dignity is being compromised. 1. It an attempt to minimise the risk of cross infection it is recommended that the hoist be surfaced cleaned in between resident use. 2. In an attempt to minimise the risk of cross infection and possible distress to residents it is recommended that Personal Protective Equipment (PPE) are easily accessible to staff should they need them. Averill House DS0000021631.V349151.R01.S.doc Version 5.2 Page 28 2. OP7 6. OP29 It is recommended that that all photocopied documents are signed to indicate that the original had been seen. Averill House DS0000021631.V349151.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU 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 Averill House DS0000021631.V349151.R01.S.doc Version 5.2 Page 30 - 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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