Inspection on 05/05/09 for Avery Lodge

This inspection was carried out on 5th May 2009.

CQC found this care home to be providing an Poor service.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Avery Lodge 20/08/09

Avery Lodge 08/05/08

Avery Lodge 24/05/07

Avery Lodge 15/06/06

Avery Lodge 14/03/06

Avery Lodge 09/05/05

Avery Lodge 13/12/04

Avery Lodge 17/05/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 20/07/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Avery Lodge 93 Southtown Road Great Yarmouth Norfolk NR31 0JX     The quality rating for this care home is:   zero star poor service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Jane Craig     Date: 0 5 0 5 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 30 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 30 Information about the care home Name of care home: Address: Avery Lodge 93 Southtown Road Great Yarmouth Norfolk NR31 0JX 01493652566 01493603627 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Mrs Sheryl Anne Hodgins,Mr Karl Michael Hodgins care home 13 Number of places (if applicable): Under 65 Over 65 13 old age, not falling within any other category Additional conditions: 0 1. The registered person may provide the following category/ies of service only: Care home only Code PC 2. The maximum number of service users who can be accommodated is: 13 to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category Code OP Date of last inspection Brief description of the care home Avery Lodge is a detached property situated in a central location between Great Yarmouth and Gorleston. It is owned and managed by Mr & Mrs Hodgins. It is registered as a care home to accommodate 13 older people. The home is a three storey building with bedrooms situated on the ground and first floors. The accommodation is spacious and has 11 single and 1-shared bedrooms; nine of the bedrooms have en-suite facilities. The communal areas consist of three lounges and one dining room, all on the ground floor. Access to the first floor can be via a chair or Care Homes for Older People Page 4 of 30 Brief description of the care home shaft lift. The front garden has been landscaped and has a seating area overlooking the pond and flowerbeds and the rear has a small car parking area, both enable wheelchair access. Information about the home, including the last inspection report is available on request. In May 2009 the weekly fees were 300 to 342 pounds. The fees did not include toiletries, hairdressing and chiropody. Care Homes for Older People Page 5 of 30 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: zero star poor service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The last key inspection on this service was completed on 8th May 2008. This key (main) inspection includes information gathered since the last inspection and an unannounced visit to the home. The visit was carried out on 5th May 2009 and was conducted by one regulatory inspector. At the time of the visit there were twelve residents in the home. We talked to some of them individually and others in a group. We asked about their views of Avery Lodge. We spent time observing daily routines in the home and how staff interacted with residents. Three residents were case tracked. This meant that we looked at their care plans and other records and talked to staff about their care needs. Care Homes for Older People Page 6 of 30 We talked to the registered manager, staff and visitors. We looked around the home and viewed a number of documents and records. What the care home does well: What has improved since the last inspection? What they could do better: After the last inspection two of the requirements we made for improvements were not met and have been repeated. These are in the areas of information about the home and medicines management. The commission may consider taking enforcement action to ensure these improvements are made. The service users guide must be revised to ensure that it provides people who use, or are thinking of using, the service accurate and meaningful information about the home. All residents must have current care plans to support them to meet their health, personal and social care needs. The residents must be given opportunities to be involved in drawing up and reviewing their care plans. The plans must be kept up to date and amended whenever the residents needs change. Risks to residents health and safety must be assessed and plans drawn up to minimise the risk. The assessments and plans must be kept under review. The policies and procedures for managing medicines must be revised to ensure that staff have adequate written guidance. There must be a clear and accurate procedure to assist anyone wishing to make a complaint about the home. The safeguarding procedure must be available to all staff to ensure they have guidance to refer to in the event of an incident of suspected, or Care Homes for Older People Page 8 of 30 actual, abuse. The manager should continue with the audit of the environment and draw up a plan of work to make sure that there is a good standard of cleanliness and decoration throughout. There must be a formal system in place to monitor and improve the quality of the home. It should include seeking views of residents and other people who have an interest in the home. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 9 of 30 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 30 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The shortage of accessible information for people thinking of moving into the home could result in them not being clear about the service to be provided. Evidence: The previous requirement, to revise the content of the service users guide and make it more accessible, had not been met. There was a booklet of policies that people thinking of moving into the home could look through, but these were not easy to negotiate and some of the information was only relevant to staff. The manager encouraged prospective residents and their families to visit the home at least once before admission to talk about the service and the residents expectations. One resident told us that they had visited a few homes but Avery Lodge was the most friendly. The manager obtained assessments carried out by health and social care professionals Care Homes for Older People Page 11 of 30 Evidence: before confirming that the service could meet the needs of a prospective resident. She also conducted her own assessment and discussed the placement with senior staff at the home. This was to ensure that the new person would fit in with the current group of residents. The assessments we saw were brief and there was not enough information to draw up an initial care plan. However, staff said they received enough verbal information to understand the residents needs and provide the right care. Standard 6 is not applicable as Avery Lodge does not provide intermediate care. Care Homes for Older People Page 12 of 30 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The lack of assessments and care plans could result in residents health and personal care needs not being met. Evidence: We looked at the files of three residents as part of the case tracking process. None of these were up to date. There were no care plans to address the residents current health and personal care needs. Although the staff we spoke said they knew the residents very well and understood the care they needed, the reliance on verbal instructions increases the risk of misunderstandings and inconsistencies in care. There was a lack of guidance for responding to mental health needs. For example, the notes for two people showed that they sometimes behaved in a way that was difficult for staff to manage. The lack of care plans could result in staff not responding to the situation in the same way. This could be confusing and potentially distressing for the residents. Care Homes for Older People Page 13 of 30 Evidence: Daily notes were generally of a good standard and included detail about the residents needs and the care they had been given. Staff said they used these notes to keep up to date. However, this made it difficult to track changes in care and the reasons for this. It also meant that residents or relatives were not involved in planning and reviewing care. The residents we case tracked had moving and handling assessments but two of these were not dated and there was no evidence of review. It was not clear whether the information was still relevant. Staff had training in moving and handling techniques and there was a range of equipment available. We observed staff assisting a resident to move without using the correct equipment but this was rectified immediately. There were no other assessments to identify and monitor other risks to residents health and safety. For example, risks caused by falls or use of bed rails. Despite the lack of appropriate health care assessments and plans, residents health was monitored. They had routine chiropody and optician appointments and they were referred to health care professionals if they needed treatment. At least one resident made their own GP appointments. A member of staff said, we know the residents so well, sometimes we know they are ill before they do. Residents told us that they were very well looked after. They were supported to attend routine screening and one said that when they were not feeling well the staff called the doctor straight away. Another said that their health was better since being at the home. Relatives said they were informed of any new health care needs. Staff received training in core values during their NVQ courses. Those we spoke to gave examples of how they promoted privacy and dignity on a daily basis. One said, We make sure no-one ever feels uncomfortable or embarrassed. Throughout the course of the visit we observed staff talking with residents in a polite and friendly manner. One of the residents we spoke to said, It is just like being in your own home and everyone is treated the same. Another said, they are good at respecting your privacy when you are in your bedroom. A family carer said they appreciated that their relative always looked clean and tidy and their hair and nails were done. The previous requirement to improve the policies and procedures for medication had not been met. The guidance in place was too brief and did not cover all aspects of medicines management. However, all staff who took responsibility for administering medication had received training and the practices for managing medication were generally safe. There were complete records of medicines received, administered and disposed of. The Care Homes for Older People Page 14 of 30 Evidence: medication administered from the monitored dose system matched the records, which indicated residents were receiving their medication as it was prescribed. There were no records of stocks of medicines carried forward from the previous month. This meant the audit trail was not complete, which could increase the risk of mishandling. There were no plans to direct staff when to administer medication that was prescribed, when required but the manager told us that all the current residents could tell staff whether they needed their medication or not. When the instructions on the medication administration record (MAR) chart indicated a variable dose, staff recorded the amount given. This helped them to be able to track how much medicine the resident was having and whether the dose was effective. There was no evidence that handwritten entries on MAR charts were double checked to reduce the risk of transcribing errors. Medication was stored securely and there was good stock control. However, medication that should be discarded after a specific period of time was not dated on opening. This meant that staff would not be able to tell when it was out of date. Controlled drugs were stored, recorded and administered in accordance with good practice guidance. Care Homes for Older People Page 15 of 30 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents had choice and control over their daily lives. Evidence: None of the care files we saw included a social care needs assessment or plan. There was some information about residents likes and dislikes and preferred routines but this was not used for care planning purposes and it was not clear whether staff used the information in their day to day care. Residents views about organised activities were mixed. Several people told us that they enjoyed the entertainer who came into the home every few weeks. They also talked about how special events were celebrated. One said, we always have a lovely time at Christmas, and another said, Everyone has a birthday party with food and entertainment. There were no records to evidence what other activities were on offer. One resident said, There is not really enough to do, thats the trouble. Another told us, The staff do things if they get the chance but it does get boring sometimes. Some residents were able to go out on their own and they appreciated that they could come and go as they wished. One told us, As long as I let them know, I have the freedom to do what I want. Some other residents went out with family. A member of Care Homes for Older People Page 16 of 30 Evidence: staff told us they were hoping to organise some trips over the summer. Staff said that they encouraged residents to make choices about their daily lives. One said that if the resident did not have the capacity to make their own decisions, the staff would suggest things rather than tell them. A resident told us, it is not regimented, were not told where we have to sit. Another told us, you can more or less please yourself. The manager told us that residents were encouraged to be involved in all decisions about the home, large or small. The residents we spoke to were all pleased with the home and said it met their expectations. One commented, Nothing could be better at the moment. Another said, It is lovely living here, I wouldnt want to move. Residents described Avery Lodge as friendly and homely. Two of the residents did small jobs around the house and garden. The manager said, They like to contribute to the upkeep of their home. There was open visiting which helped residents to maintain contact with their family and friends. Visitors told us they were made to feel very welcome. One resident told us that one of his family came for lunch every week just as they had before he came into the home. All the residents we spoke to said they enjoyed the meals. One told us, There is a good selection, and others commented that they were very good. The records of meals showed that residents were offered a varied and balanced diet. There were two choices at each meal, the manager said one was usually a traditional meal and the other introduced new tastes. One resident told us they had just had prawn curry which they described as, more interesting. There were two sittings at lunch, which was to ensure that people who wanted to have a lie in and a late breakfast were not faced with another meal straight afterwards. Care Homes for Older People Page 17 of 30 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The lack of clear procedures could result in complaints and safeguarding incidents not being handled appropriately. Evidence: The complaints procedure had been revised, as we previously required, but some of the information and contact details were still out of date. A copy was included in the service users guide but not given to all residents. None of the residents or visitors we spoke to said they had seen the complaints procedure but all said they would feel able to speak to the manager or other staff if they needed to. Several residents told us that they had no grumbles or complaints. There had been no complaints either to the Commission or directly to the service since before our last inspection. All staff had received recent training in safeguarding. The Norfolk County Council procedure for the protection of vulnerable adults was available to staff for reference purposes. However, the procedure specifically for the home could not be located at the time of the visit, therefore it was not possible to judge how useful it was in providing guidance to staff. The staff we spoke to at the time of the visit said they thought they would be able to detect the signs if any of the residents were the victims of abuse. They were clear about their responsibilities to report. One said, That is the way we have been trained. The manager was also clear about her role. There had been no safeguarding referrals. Care Homes for Older People Page 18 of 30 Care Homes for Older People Page 19 of 30 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Not all areas of the home were clean and maintained to a good standard. Evidence: The manager had commenced an audit of the environment and highlighted a number of areas in the home that were in need of redecoration and renewal. Some new items had been purchased and the kitchen was in the process of being replaced but there was no formal plan to show the timescales for all work to be completed. The communal areas of the home were comfortable, the lounges had recently been decorated and there were bookcases and other touches which gave a homely feel. The dining room was in need of redecoration. Residents and visitors described Avery Lodge as, Homely and nice, and one said, I am very pleased with the place. The front garden had been thoughtfully arranged to provide a choice of walkways and seating areas. One resident said they sometimes went out to watch the fish and another told us,It is lovely outside in the summer. There was an area at the back of the house where old equipment was being stored, which created an unsightly view from the rooms overlooking the area. The bedrooms we saw were personalised with small items of furniture, ornaments and Care Homes for Older People Page 20 of 30 Evidence: pictures. One resident said their room was basic but had everything they needed. Other residents told us they were happy with their bedrooms. Privacy screens were available in the shared room and most of the bedrooms we looked at had safe storage for personal or valuable items. Windows had restricted openings to increase safety and security. Only one radiator was guarded. There were no risk assessments to show that the unguarded radiators did not pose a risk to residents, especially those with a history of falls. A number of the rooms we saw were in need of a deep clean. One person told us that the standards of cleanliness had slipped recently although they said it was nothing extreme. The manager had already noted this and had taken steps to improve the situation. We were told that all the laundry was once again being done on the premises. The manager said that there was sufficient equipment and staff hours for the size of the home and number of residents. There were no complaints about the laundry and at the time of the visit residents clothing looked to be well cared for. Two senior staff had attended infection control training recently and were intending to cascade the information to the other staff. There were gloves and aprons for staff use and a member of staff told us that the staff knew about the importance of hand washing. Care Homes for Older People Page 21 of 30 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There were sufficient staff, with appropriate training, to meet the needs of residents. Evidence: The staffing rosters showed that the home was always staffed to the target levels and there was always a senior person on duty. Residents, visitors and staff we asked said they thought there were always enough staff on duty. A visitor said, there is always someone about if you need them. One of the residents told us that although there were enough staff to attend to everyone, they were very busy and did not always have time to sit and talk. There was a low turnover of staff and most had been at the home for a number of years. This helped residents to build up good relationships and all those we spoke to praised the staff team. One said, You couldnt get better people to run it, the staff are brilliant. Another told us, Staff are all very friendly. There had been no new staff since the last inspection, therefore, we were not able to evidence whether a previous requirement to improve recruitment processes had been met. The manager was clear about the pre-employment checks that needed to be carried out before new staff could start work at the home and said these would be adhered to during future appointments. Care Homes for Older People Page 22 of 30 Evidence: The manager discussed that new staff went through an initial induction programme that covered health and safety, emergency procedures and practice issues. However, it was not clear whether the training covered all the topics recommended in the Skills for Care Common Induction Standards. There was no central training record, therefore we were not able to evidence what training each member of staff had received in the last year. The manager said that most of the mandatory topics had been covered and staff had attended or were due to attend a number of other courses relevant to their role. For example, dementia care, managing difficult behaviour, and end of life care. The staff we spoke with said the opportunities for training were good. All care staff had achieved or were undertaking NVQ level 2 and several had level 3. Care Homes for Older People Page 23 of 30 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Management and administration systems were not effective enough to ensure that residents always received a good quality service. Evidence: The registered manager is experienced and qualified and is highly regarded by residents, staff and visitors. However, she has had several health related absences over the past year, which has impacted on the management and administration of the home. Several shortfalls have been highlighted in this report. The manager was already aware of most of these and had plans for improving the service, especially in the areas of care planning, the environment and training. There had been no formal quality monitoring since before the last inspection. The manager told us that she would be re-introducing a system to enable residents, relatives and other stakeholders to feedback their views of the service. Policies had not been reviewed for over a year and a number of these were in need of amendments to Care Homes for Older People Page 24 of 30 Evidence: ensure that they reflected current practice. There were no audits of systems and processes, and records that were required to be kept were not all complete. Several residents managed their own money, others were supported by family or other representatives. The manager did not hold any money or valuables on behalf of people using the service. Secure facilities were available if needed in an emergency. Despite not having input into managing residents finances the manager had quickly identified that a resident was being taken advantage of by a member of the public, and had put systems into place to prevent this continuing. The manager told us that all staff had received fire safety training but there were no records to evidence this. The records of practice drills and fire alarm tests were not up to date. Residents told us they had been involved in fire drills and knew what to do if the fire alarm sounded. Fire safety equipment had been serviced recently. Servicing and maintenance of other installations and appliances were up to date or had been arranged. Care Homes for Older People Page 25 of 30 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 1 5 (1) a b c d e f (2) That the services service 30/08/2008 user guide be revised to ensure that its content and usage complies with regulation in order to ensure that people have the necessary information about the home. That the provider revise the 30/08/2008 homes medication policy to ensure that it provides clear and comprehensive guidance as to the arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines, in order to help ensure the safety of residents. 30/08/2008 2 9 13 (2) 3 16 22 (1) (2) (3) That the provider revise the (4) (5) (7) complaints procedure in line with regulation to ensure that people have a clear understanding how to complain and the process that will be followed. Care Homes for Older People Page 26 of 30 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 1 5 A service users guide must be produced. In order to provide essential information to people thinking of using the service. 31/07/2009 2 7 15 Everyone using the service must have a care plan to address their health, personal and social care needs. The care plan must be kept under review and amended as the persons needs change. In order to support people using the service to meet their needs. 31/07/2009 3 8 13 Risks to residents health and 30/06/2009 safety must be assessed and plans drawn up to control the risk. These would include risks associated with falls and the use of bedrails. In order to protect residents. Care Homes for Older People Page 27 of 30 4 9 13 There must be a complete set of policies and procedures for the management of medicines. To provide guidance to staff on safe handling. 28/08/2009 5 33 24 There must be a system for monitoring and improving the quality of the service. This must take into account the views of people using the service. To ensure that the home is run in the best interests of the people who live there. 30/09/2009 6 37 17 Records relating to the safe management of the home must be complete and up to date. To protect the health, safety and welfare of residents and staff. 31/07/2009 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 3 The pre-admission assessment should be further developed to assist staff to gain a full picture of the prospective residents needs and abilities. In order to continue the audit trail there should be records on the MAR charts of stocks of medication carried forward from the previous month. Medication with a short shelf life should be dated on opening. The programme of group and one to one activities should be further developed to meet residents social and recreational needs. Page 28 of 30 2 9 3 4 9 12 Care Homes for Older People 5 18 There should be a safeguarding policy/procedure specifically relating to Avery Lodge to ensure that staff know what to do if they suspect or are told a resident is the victim of abuse. A full audit of the environment should be carried out and a plan of redecoration and renewal drawn up. All policies and procedures should be reviewed to ensure that they reflect current good practice. 6 7 19 37 Care Homes for Older People Page 29 of 30 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. 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