CARE HOMES FOR OLDER PEOPLE
Avon Court All Saints Road Warwick Warwickshire CV34 5NP Lead Inspector
Lesley Beadsworth Key Unannounced Inspection 29th June 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Avon Court DS0000004490.V299857.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. Avon Court DS0000004490.V299857.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Avon Court Address All Saints Road Warwick Warwickshire CV34 5NP 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) 01926 401324 01926 401324 info@prime-life.co.ukwww.prime-life.co.uk Prime Life Limited Care Home 34 Category(ies) of Old age, not falling within any other category registration, with number (34) of places Avon Court DS0000004490.V299857.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 16th March 2006 Brief Description of the Service: Avon Court (owned by Prime Life Ltd) is a care home providing personal care and accommodation for up to 34 service users over the age of 65 years. Accommodation consists of all single bedrooms, over two floors. The services offered in this home are all based on rehabilitation. Two types of service are provided, intermediate care and transitional care. Avon Court does not take any privately funded service users. Service users are admitted from hospital or the community following assessment by the Intermediate Care team and the home manager. Accommodation on the first floor is for service users receiving rehabilitation and the ground floor offers personal care services. Service users admitted to this home are funded either by the local Primary Care Trust, for rehabilitation or social services for assessment and transitional care. Service users in this home are all short stay. The average length of stay is six weeks. The majority of service users then return home or move into care homes on a long-term basis. The services provided are delivered by the home’s care staff and professional therapists employed by the Primary Care Trust. The therapeutic services provided are based on person-centred care and current evidence-based practices. At the time of the inspection fees at the home were the local authority rate of £344.94 per week. These fees do not include hairdressing and chiropody. Avon Court DS0000004490.V299857.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one day from the hours of 09:30 and 17.30. The manager, and other members of staff present, cooperated fully with the inspection process. The inspection included a tour of the premises, talking with the manager, staff and residents, looking at resident records, case tracking, examination of staff records, and policies and procedures. Time was also spent observing care delivery and staff/resident interactions. Other information was also collected from a variety of sources prior to visiting the home. What the service does well:
The manager demonstrated a clear vision for the home and a good understanding of the areas in which the home needs to improve. All the residents spoken with said that they were satisfied with the care that they received at the home. Comments made by them included, “Everyone is very pleasant. We’re well looked after”; “very happy here”; “Nobody can grumble about anything here”; “all good from the food to the attention.” “ Call bells are answered straight away.” The home was free of any offensive odour and all areas viewed were clean and in the main well decorated and furnished, offering the people staying at the home comfortable surroundings. The gardens were tidy and well maintained with garden furniture for use by residents. Several residents and visitors were enjoying the use of the garden throughout the inspection. All areas of the home are accessible to residents by means of a passenger lift to both floors and ramps to the outside of the building. There is a dedicated Intermediate Care unit on the first floor of the home where residents receive intensive assessment and rehabilitation with the aim of returning home again. Therapists employed by the Primary Care Trust (PCT) including physiotherapists, occupational therapist, a part time pharmacist and generic support workers are present during the day with care staff from the home being available 24 hours a day. Maintaining and improving independence and helping residents to re-learn skills to enable them to move back into the community are key objectives of the home. Avon Court DS0000004490.V299857.R01.S.doc Version 5.2 Page 6 Residents spoken with said that the food was very good and the food served at the time of the inspection looked appetising and well presented. The menus offer a choice of main meals and of vegetables and desserts. A recent Fire Service Inspection had taken place and a satisfactory report had been received. The manager has updated the fire risk assessment for the home. What has improved since the last inspection? What they could do better:
All residents prior to admission must be assessed to demonstrate that they are suitable for Intermediate Care or Transitional Care and that the service can meet their needs. Care plans must include sufficient detail to give staff information regarding the health and welfare of residents and to enable those needs to be met. The care prescribed must be evaluated and changed as required with a minimum of monthly intervals. To ensure social mental and physical stimulatio residents must be included in the decisions made concerning their social and leisure interests. Avon Court DS0000004490.V299857.R01.S.doc Version 5.2 Page 7 The temperature of cooked foods must be recorded and the service must ensure that food served is at the appropriate temperature to prevent infection and increase the experience of eating. The complaints policy should be written in a way that enables the complainant to easily follow the procedure and records of any complaints or concerns raised with the actions taken by the service must be kept in the home. In order to maintain a safe and hygienic environment the cracked sinks and stained bath must be repaired or replaced and the rear staircase made safe; the kitchen still requires refurbishment . All doors to rooms used for storage should be kept locked. The home needs to achieve NVQ Level 2 in Care for 50 of the care staff. The registered person must ensure that all care staff receive supervision at the required frequency of six times a year so that staff have the opportunity to discuss training development, care practices and the philosophy of the home and to be involved in the way the services are provided. The registered person must ensure that the person undertaking the unannounced Regulation 26 visits examines the medication records, staff files and service users ’ care records to ensure that an opinion is formed of the standard of care in these areas of previous concern. Walking aids should be discreetly labelled to enable the owner to be identified and to ensure that people are using the correct aid. It is recommended that a discharge process and summary record be developed that can be filed with the service users record. 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. Avon Court DS0000004490.V299857.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 Avon Court DS0000004490.V299857.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,4,6 The quality of this outcome group is adequate. This judgement has been made using available evidence including a visit to this service. The well being of the residents is compromised by the lack of residents’ contracts and assessment information. EVIDENCE: The Commission approves the Statement of Purpose and Service User Guide generically for the organisation. Avon Court’s version is in the process of being updated following the recruitment of a new manager. None of the care files viewed contained a contract between the resident and the home. Discussion with the manager showed that the contract is a threeway agreement between the resident, the home and Social Services and that there is frequently a delay in these being forwarded by Social Services who initiate them. The manager is then expected to ensure that the resident signs the contract and several were waiting for this to take place at the time of the inspection. Given the turnover of the home this is an on going task . The delay in contracts arriving at the home means that residents and their families are
Avon Court DS0000004490.V299857.R01.S.doc Version 5.2 Page 10 unclear about the conditions of their stay, the fees expected, extra costs and the overall care they should expect. The manager advised that the home could cater for emergency admissions and that all required documentation, such as assessments and care plans are provided within 48 hours of admission. Three care files were examined. One care file for an Intermediate Care resident had the Single Assessment carried out by health/social care managers prior to admission, which although covered the required assessment areas was difficult to access relevant information. There were no corresponding care plans to direct staff to the needs of this resident. Two care files for residents admitted for transitional care were also examined and it was found that only one file contained an assessment. It was noted that a large weight loss was identified for a resident prior to admission, whilst in hospital. No risk assessed was seen and there was no care plan. These shortfalls have the potential to put the resident at risk of malnutrtion. It also demonstrates that there has been no consideration about whether the needs of the individual can be met at the home. Records and discussion with the manager demonstrate that there has been some progress in staff undertaking training related to dementia and nutrition and a resource file having been set up for staff regarding other specialist needs. There needs to be further specialist training enabling staff to increase their knowledge and skills related to conditions that are experienced by people who come to stay at Avon Court. There is a dedicated Intermediate Care unit on the first floor of the home where residents receive assessment and rehabilitation with the aim to return home. Staff from the Primary Care Trust (PCT), including physiotherapists, occupational therapists, a part time pharmacist and generic support workers, staffs this unit during the day. Care staff from the home provide personal care. The average stay for these residents is six weeks but there is some flexibility in this. There is an identified therapy room and appropriate equipment for rehabilitation. Equipment is supplied by the PCT as required by the individual resident. There is a small flat in this unit that is intended to be used for rehabilitation this was not in use at the time of the inspection. The manager advised that there is good communication between her and the Primary Care Trust staff and a member of the Intermediate Care Team said in an Avon Court comment card that everyone was now working together to make the scheme work and improve care. A member of the Primary Care Avon Court DS0000004490.V299857.R01.S.doc Version 5.2 Page 11 Trust spoken with said that “communication channels are excellent” between the two teams. Avon Court DS0000004490.V299857.R01.S.doc Version 5.2 Page 12 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 The quality of this outcome group is adequate. This judgement has been made using available evidence including a visit to this service. There is a risk of residents well-being becoming compromised by the lack of details in the care plans available to staff to enable them to provide the care required. EVIDENCE: The manager has developed a new care plan format, with the information care staff require being far easier to extract than previously. All but one care file of the three examined contained plans of care to inform care staff of the needs of the resident and the care required. There was some lack of detail, for example one care plan stated that assistance was needed with personal care but no further information given as to what areas of personal care this referred to and what assistance was involved. A pre-admission assessment stated that a resident had experienced a large weight loss but this was not addressed in the care plan to inform staff what care they needed to provide with regard to this.
Avon Court DS0000004490.V299857.R01.S.doc Version 5.2 Page 13 The care plans looked at had been reviewed monthly and some revisions had been made to reflect changes in circumstances. A further care file contained a risk assessment related to pressure sores and although this indicated that there was a high risk of pressure sores developing there was no further reference to this in a care plan. There are no residents reported to have pressure sores and equipment for the prevention of pressure sores development were available in the home. The home has GP contact on an almost daily basis. There is also access to other health professionals such as dentist, optician, chiropodist and district nurses. Pprogress has been made in improving the medication management and administration practicesea and that the manager she is planning further improvement to the practices and procedures. New procedures regarding home remedies and self-administration of medication are currently in draft form. A book showed that medications brought into the home from the pharmacy is received and recorded by a member of staff and that medication is stored safely. The manager said that she audits the medication and Medication Administration Record Sheets (MARs) at a minimum of weekly intervals. Any discrepancies with administration or gaps found in Medication Administration Record Sheets are discussed with the relevant member of staff. Records of these meetings were viewed. A copy of each record is kept at the organisation’s human resources department. The administration of medication was seen to be in line with the home’s policies and procedures. However it was noted that a member of staff administered eye drops to a resident whilst at the dining table which is not considered appropriate. The member of staff discussed this with the manager afterwards and accepted that this had not been good practice. Risk assessments are carried out to assess if a resident is able to self administer their own medication. The Primary Care Trust pharmacist is working with Intermediate Care Unit auditing the self administration of medication with the residents in that unit. Records showed, and the manager and staff spoken to confirmed, that the staff responsible for medication have now attended appropriate training and the manager has also given further training in-house. Avon Court DS0000004490.V299857.R01.S.doc Version 5.2 Page 14 The interaction between staff and residents was seen to be respectful and residents and visitors spoken with confirmed this. All laundry is done by the resident’s family or representative, other than in an emergency. A payphone is available in a corridor for the use of residents. Avon Court DS0000004490.V299857.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13,14,15 The quality of this outcome group is good. This judgement has been made using available evidence including a visit to this service. Residents are given choice and assisted to meet their own social and leisure activities. EVIDENCE: The manager stated that there is an activity programme that is dependent on the residents’ wishes and other therapy programmes taking place. No activities were observered during the inspection. Birthdays are celebrated at the home and one resident talked about the party she had and enjoyed for her 90th birthday. Other special events are also celebrated and recently the residents had been provided with a buffet tea whilst watching the World Cup football matches. Other occupations include shopping, ‘creative mobility’, and monthly outings in the vehicle belonging to the organisation. Records are being kept of activities and outings provided by the home. Adequate and appropriate activity and occupation, geared to meet the wishes and preferences of residents, is important to maintain mental and physical stimulation. Avon Court DS0000004490.V299857.R01.S.doc Version 5.2 Page 16 There were several visitors to the home during the inspection and those spoken to said that they were always made very welcome. This was further confirmed in a completed comment card returned by a relative. Visiting hours are at any reasonable time and the only restrictions imposed were those that could be made by individual residents. Maintaining and improving independence and helping residents to re-learn skills to enable them to move back into the community are key objectives of the home. Discussion with residents, staff and the manager demonstrated that residents are assisted to exercise choice and control over their lives, for example in choice of meals, where they spend the day and times they go to bed and rise in the mornings. Residents are encouraged to bring in small personal items and such as photographs were seen in bedrooms. However the short length of time that residents stay may limit what they bring with them. The manager explained that residents’ meetings were not necessarily appropriate in this home due to the short term nature of the stay by the majority of people living at the home. The dining room is acceptable it had been previously suggested that this area was due for redecoration. The kitchen was found to be clean, but there remains a risks of contamination from some of the worktops, particularly the badly stained stone slab in the pantry, and risk of slipping if the kitchen floor is wet. This area is due for refurbishment the manager advised that she was expecting work to begin in the very near future. The manager was asked to complete a risk assessments in relation to the residents’ health, safety and well being whilst the kitchen is out of use and forward a copy to the Commission. The store cupboards contained a good selection of food, including such ‘treats’ as crisps, ice cream cornets and biscuits. The majority of the food was stored correctly but a packet of meat had been opened and was not labelled or dated. Potatoes, in a sack, were stored directly on the floor . All food should be stored off the floor to prevent contamination and to prolong their freshness. A wide variety of fruit squashes and juices were available and a wide choice was being offered to resident throughout the very warm day that the inspection took place. Residents spoken with said that the food was very good. The food served on the day looked appetising and well presented. The menus offer a choice of main meals and of vegetables and desserts. The majority of the staff have undertaken training related to nutrition and healthy eating in order to assist in offering a good nutritional service. Food is taken to bedrooms without the benefit of a heated trolley, plates are, however, covered with plate lids that assist in maintaining some heat. Food
Avon Court DS0000004490.V299857.R01.S.doc Version 5.2 Page 17 must be served at the correct temperatures and the home needs to maintain records to demonstrate that this is the case. Avon Court DS0000004490.V299857.R01.S.doc Version 5.2 Page 18 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 The quality of this outcome group is adequate. This judgement has been made using available evidence including a visit to this service. Although there are some shortfalls the residents are considered safe with the procedures and practices in place. EVIDENCE: The home has a complaints policy that is available to people living at the home, a simplified version is recommended for the use of residents. Information regarding a complaint made to the home was not available despite advising the home that all records are required to be kept on the premises which must include the actions taken. The manager produced a format that will ensure the confidentiality of others if a person wishes to access their own information and is therefore in line with the Data Protection Act. The Adult Protection Policy gives clear information regarding the making of a referral in the event of actual or alleged abuse.However, there is no information on the action to be taken in regards to the suspected abuser or the care of an adult who may have been abused. The Policies and Procedures require up dating so that it includes the issues above. Eighteen staff, including catering and domestic staff, have attended training related to the protection of vulnerable adults enabling them to identify abuse and protect those living at the home.
Avon Court DS0000004490.V299857.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22, 26 The quality of this outcome group is good. This judgement has been made using available evidence including a visit to this service. Aapart from a few minor shortfalls residents enjoy comfortable, clean and safe surroundings inside and outside of the home. EVIDENCE: The home was clean and free of offensive odours and appeared homely and comfortable. Décor and furnishing were of a good standard although some of the furniture in the ground floor bedrooms did not match and an armchair in one of the rooms viewed was very worn. The home is generally well maintained apart from the cracked sinks and the need for the kitchen to be refurbished which were noted at the last two inspections. The home has two pleasant lounges and a large dining room on the ground floor, with a further lounge on the first floor. Only a few residents occupied these lounges on the day of the inspection with several residents making use of the attractive and well kept gardens in the good weather and others using their bedrooms.
Avon Court DS0000004490.V299857.R01.S.doc Version 5.2 Page 20 The rehabilitation flat was not in use by residents at the time of the inspection and was mainly being used for storage. It is suggested that doors to rooms not in use by residents or staff, especially when being used for storage, should be locked for reasons of safety. The stairway at the rear of the home was cluttered and housed an unlocked storage room. The stairs were dirty and the ceiling light fitting was without a shade. Apart from being unsightly this area could pose a safety risk to any resident accessing the staircase. A recent Fire Service Inspection had taken place and a satisfactory report had been received. The manager has updated the fire risk assessment for the home. The laundry was in good order with a new washing machine in place although the temperature of each programme was not shown on the dials. It would assist staff to have a code to this, which is presumably available from the instruction manual. However the majority of the laundry is not carried out in the home with family and friends being relied upon to carry out the washing of personal items. Bed linen is sent out to a laundry contractor. Not all walking aids are labelled with the owner’s name. This has the potential to cause confusion, and relies on the memory of members of staff for the aids to be returned to their rightful owner, which may also contribute to an increased risk of falls and accidents if given the wrong waalking aids. The risk of this occurring is high given the rate of admission and discharge of residents in this home. A risk assessment needs to be carried out and appropriate action taken. On the Intermediate Care Unit there is an identified therapy room and appropriate equipment for rehabilitation and equipment is also supplied by the Primary Care Trust as necessary to further develop the rehabilitation of the individual resident. All areas of the home are accessible with the aid of ramps to the outside areas and a passenger lift to both floors. There were no concerns relating to infection control practices in this service. Twenty-four staff have attended infection control training since the last inspection and therefore have increased their knowledge and skills in this area. infection control. Avon Court DS0000004490.V299857.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 The quality of this outcome group is good. This judgement has been made using available evidence including a visit to this service. The policies and practices protect the people living at the home. EVIDENCE: Through observation and records it was confirmed that there are sufficient staff to meet the needs of the people living at the home. There is suitable domestic cover seven days a week, freeing the care staff from this duty. The home continues to have access to staff from the other homes in the organisation to cover absences. All the residents spoken with said that they were satisfied with the care they received at the home, comments included, “Everyone is very pleasant. We’re well looked after”; “very happy here”; “Nobody can grumble about anything here.” “all good from the food to the attention. Call bells are answered straight away.” There have been several staff changes in all departments since the last inspection and the manager advises that is partly due to performance management. Three staff records of recently appointed staff were examined. Two of these files contained all the appropriate information and Protection of Vulnerable Adults (POVA) and Criminal Records Bureau (CRB) checks.
Avon Court DS0000004490.V299857.R01.S.doc Version 5.2 Page 22 The third file did not have a CRB check but had a POVA 1st check to confirm that the employee had not been added to the POVA register. The manager was aware of the need for the member of staff to be supervised until the Criminal Records Bureau check had been cleared. It was also noted that one of the employees had started work at the home before a POVA 1st or Criminal Records Bureau check had been received at the home, this is now available. This had the potential to put residents at risk of being cared for by inappropriate people. The manager demonstrated that since her appointment in April she has made staff training an important factor. Training has included, updating of all mandatory training, infection control, medication, nutritional screening, healthy eating, and Protection of Vulnerable Adults. Although the home has still not achieved 50 of the care staff with a National Vocational Qualification (NVQ) Level 2 in Care several more care staff have begun this training. An induction and foundation programme for new staff is also now in place. A training record and spreadsheet for the staff team is available making it easier to monitor training that has been completed and to identify their training needs. Training to meet the specialist needs of people staying at the home is still required. Avon Court DS0000004490.V299857.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 The quality of this outcome group is adequate. This judgement has been made using available evidence including a visit to this service. There are limited quality assurance measures in place, however, there are safe practices in place. EVIDENCE: The new manager has been in post for three months. She has not yet completed her registion with the Commission. She is a Registered General Nurse, an Enrolled Nurse in Mental Health, has a City and Guild certificate in teaching, the Registered Managers Award and has been trained in dementia with Stirling University. She has also undertaken training in infection control and health and safety. She has had several years experience as a registered manager in other homes belonging to the organisation.
Avon Court DS0000004490.V299857.R01.S.doc Version 5.2 Page 24 Discussion with the manager demonstrated that she had a clear vision for the home and a good understanding of the areas in which the home needs to improve. Weekly senior meetings are held, two staff meetings have occurred in the past three months giving the staff the opportunity to affect the way that the service is delivered and help to create an open management style. Staff spoken to said that there has been a great improvement in care in recent months and that they find the manager approachable and offering an on going opportunities to learn. The manager also attends the weekly meetings with Primary Care Trust team, regarding residents’ progress and potential discharges, whenever possible to aid communication and information sharing. The Responsible Individual or representative completes Regulation 26 reports after a monthly, unannounced visit and a copy is retained at the home. These demonstrate that the organisation is monitoring the service. However it was noted that the requirement to include monitoring of medication, staff records and residents records in these reports was not met, and there was no further evidence to demonstrate that those areas of previous concern have been monitored during the Responsible Individual’s visit. The home distributes their own comment cards that to residents, visitors, staff and other professionals or interested persons, for their feedback on the home and the services provided. Copies were seen and contained positive comments. The comment cards do not offer an anonymous option, which could provide an opportunity for more objective responses. There was no further evidence of a quality assurance programme in place at the home. The home does not hold money on behalf of residents and encourages them to look after small amounts of cash themselves. The manager is aware that if any money, or valuables, is held for residents that all transactions must be recorded. The manager advised that some staff supervision had taken place and one member of staff confirmed this. However not all staff have done so in the short time that the manager has been at the home. All maintenance and service checks were up to date. The manager advised that all mandatory training was completed. A recent fire service inspection was satisfactory and the home’s fire risk assessment has been revised. A recent fire drill had taken place and showed the names of all who were present. A system of risk assessments are in place and the organisation has Avon Court DS0000004490.V299857.R01.S.doc Version 5.2 Page 25 appropriate policies in place. The manager is in the process of individualising these and ensuring that there are relevant procedures in place. Avon Court DS0000004490.V299857.R01.S.doc Version 5.2 Page 26 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 2 3 2 3 X 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 3 Avon Court DS0000004490.V299857.R01.S.doc Version 5.2 Page 27 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 OP1 Regulation 4 Requirement A up to date Statement of Purpose and Service User Guide, must be a vailable for both prospective and permanent residents. Each resident prior to admission to the service must have a completed assessment of needs, and suitable care plans must be develop. Timescale for action 31/10/06 2. OP3 14 30/09/06 3. OP7 15 Each resident must have a care 31/10/06 plan in sufficient detail to be able to guide the staff on how health and welfare needs are to be met. The care given must be evaluated and the care plan revised as the resident’s circumstances change. Food must be served at an appropriate temperature and at the point of serving. Recoulds must be maintained All information related to Concerns, complaints abnd allegations must be kept in the
DS0000004490.V299857.R01.S.doc 4. OP15 16(2)(i) 30/09/06 5. OP16 20 31/10/06 Avon Court Version 5.2 Page 28 home with action taken. 6. OP18 13(6) The Adult Protection policy must include the procedure to be followed by staff if the event of incident or allegation of abuse occuring. The registered persons must ensure that the kitchen is suitably up dated and areas that increase the risk of infection are dealt with promptly. (From the previous inspection of September 2005.) 8. OP19 23 The registered provider must ensure that all areaas of the home are in good repair, minimise the risk of cross infection and are safe. (From the previous inspection of September 2005.) 9. OP28 OP30 18(1) 12(1) The registered persons must ensure that staff have the appropriate qualifications and training to meet the needs of the service, including NVQ Level 2 in Care having been achieved by 50 of the care staff. (From the previous inspection of September 2005.) 10. OP31 9 The manager must complete the registration process. 31/10/06 30/11/06 30/11/06 31/10/06 7. OP19 12(1) 13(4) 16(2)(j) 31/10/06 Avon Court DS0000004490.V299857.R01.S.doc Version 5.2 Page 29 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 OP2 Good Practice Recommendations It is recommended that the home discuss the time taken for contracts to arrive for the residents after admission. The service should also ensure that the residents are aware of any extra costs that they will incure during their stay. Walking aids should be discreetly labelled to enable owner identification. The management are advised to produced various versions of the complaints procedure for residents to meet their various needs. It is recommended that a discharge process and summary record be developed that can be filed with the service users record. Doors of rooms used for storing items should be kept locked. 2. 3. OP22 OP10 OP16 4. OP37 5. OP38 Avon Court DS0000004490.V299857.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Coventry & Leamington Spa Office Imperial Court Holly Walk Leamington Spa CV32 4YB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
© This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Avon Court DS0000004490.V299857.R01.S.doc Version 5.2 Page 31 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
