Inspection on 04/10/05 for Avon Court Care Centre

This inspection was carried out on 4th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Avon Court Care Centre 07/07/08

Avon Court Care Centre 13/07/06

Avon Court Care Centre 18/04/05

Avon Court Care Centre 15/11/04

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

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

CARE HOMES FOR OLDER PEOPLE Avon Court Care Centre Rowden Hill Chippenham Wiltshire SN15 2AJ Lead Inspector Susie Stratton Announced 04 October 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Avon Court Care Centre D51_D01_S59517_AvonCourt_V243746_041005_Stage4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Avon Court Care Centre Address Rowden Hill Chippenham Wiltshire SN15 2AJ 01249 660055 01249 461670 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) BUPA Care Homes (CFC Homes) Limited Mrs Elissa Beaven Care Home with Nursing 60 Category(ies) of OP Old Age (60) registration, with number PD Physical Disability (2) of places TI Terminally ill (1) TI(E) Terminally ill - over 65 (1) Avon Court Care Centre D51_D01_S59517_AvonCourt_V243746_041005_Stage4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1 The maximum number of service users who may be accommodated in the home at any one time is 60 2 No more than 2 physically disabled persons under 65 years of age in receipt of nursing care may be accommodated at any one time of which one may only be the female service user named in the application 3 The staffing levels set out in the Notice of Decision dated 10 May 2004 must be met at all times 4 No more than one male or female service user may be accommodated in the home at any one time under the category of Terminally ill or Terminally ill (aged over 65). Date of last inspection 18th April 2005 Brief Description of the Service: Avon Court Care Centre provides care with nursing and accommodation, for up to 60 people. Avon Court was originally registered in 1984. It is a purpose built, two storey building, set in its own grounds. Accommodation is provided on both floors. All rooms are single. Bathrooms for general use are on both floors. There is a passenger lift. The service is owned by BUPA, a national provider of care. Mrs Elissa Beaven is the registered manager, she was appointed in May 2005. Mrs Beaven is an experienced manager and registered nurse. Mrs Beaven is supported by a deputy and leads a team of nursing, care and ancillary staff. The home is adjacent to Chippenham’s hospital. It is a short drive away from the town centre. This offers a range of shops and other amenities. There is car parking on site, a bus stop is at the end of the road and there is a railway station in the middle of Chippenham. Avon Court Care Centre D51_D01_S59517_AvonCourt_V243746_041005_Stage4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place on Tuesday 4th October 2005 between 10:00am and 5:00pm, in the presence of Mrs Elissa Beaven, registered manager. During the inspection, the Inspector met with eleven residents, observed care for sixteen residents who were unable to communicate and two relatives. The Inspector reviewed the notes of seven residents, who were met with, in detail. The Inspector also met with the deputy manager, two registered nurses, four care assistants, the chef, the administrator, the maintenance manager and the laundress. The Inspector toured the home, observed a lunchtime, an activities group and among other areas, reviewed the files of three newly employed staff, supervision records, the fire log book, maintenance records, residents financial records and files and systems for management of medicines. As part of the inspection pre-inspection questionnaires were sent out and responses were returned by 29 residents and six relatives. Since the previous inspection, two follow-up visits have been made to the home, one on 19th May 2005 and the other on 12th July 2005. Both visits showed that the home had met requirements from the previous inspection by their due date. What the service does well: What has improved since the last inspection? All nine of the requirements from the previous inspection, one additional requirement from the follow-up inspection of 19th May 2005 and seven of the Avon Court Care Centre D51_D01_S59517_AvonCourt_V243746_041005_Stage4.doc Version 1.40 Page 6 eight recommendations from the previous inspection have been addressed. The one which has not been addressed shows progress. A copy of the summary of the inspection report is now included in the service user’s guide. Frequent care charts are now accurately completed. Care planning across a range of areas is now much improved. Oxygen cylinders are fully secured. Medicines administration records are all fully completed at the time of administration. Registered nurses are complying with the home’s policies and procedure on disposal of medicines. Call bells are promptly answered. Residents’ moneys and valuables handed in for safe storage is properly stored. A full system for staff supervision and appraisal is in place. Falls care plans include reference to the resident’s footwear. Some residents documentation relating to prevention of pressure damage now include when a particular intervention/type of equipment is used. A new medicines trolley has been provided for the first floor. Handwritten instructions on medicines administration records are now countersigned. Systems have been put in place to ensure that residents are given their meals in an organised manner, that assistance is provided to those who need help with their meals and that there are enough chairs for staff to sit with residents when they assist them with their meals. All staff who are on duty now continue to work on the floor to which they have been allocated. The home’s accounting system for valuables now includes dates. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Avon Court Care Centre D51_D01_S59517_AvonCourt_V243746_041005_Stage4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Avon Court Care Centre D51_D01_S59517_AvonCourt_V243746_041005_Stage4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2 , 3 & 4 The home does not offer intermediate care. Prospective residents and their supporters are provided with full information on the service provided by the home, this includes a statement of terms and conditions with the home. Residents have full assessments of needs prior to admission. The home is able to meet the range of needs of residents in the home. EVIDENCE: The home’s service users’ guide is available in the front entrance and in each individual resident’s room. The information is regularly up-dated and includes a copy of the summary of the most recent inspection report. All of the relatives who responded to that section of the pre-inspection questionnaire said that they had access to a copy of the inspection report. BUPA has recently revised its contracts and new contracts have been sent out to all self-funding residents. The files of newly admitted residents showed that a comprehensive pre-admission assessment had taken place and that copies of relevant assessments by other professionals had been obtained. Avon Court provides care to persons with a range of nursing and care needs. This inspection showed that the home are able to meet the needs of residents in the home. Avon Court Care Centre D51_D01_S59517_AvonCourt_V243746_041005_Stage4.doc Version 1.40 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8 , 9 & 10 Avon Court have improved standards of care planning since the previous inspection. Two areas only remain. Residents could be put at risk by a lack of consistency in approach in care planning for the prevention of pressure damage and some imprecise directions in care plans could mean that staff are not properly directed on how to meet individual care needs. Safe systems are in place to ensure that medicines are properly managed. Residents privacy and dignity is up-held by the home’s polices and working practice. EVIDENCE: Avon Court have put much work into improving care plans since the previous inspection. Standard care plans have been set up, these are then individualised in specific areas relating to individual residents, for example there is a standard care plan for meeting residents’ personal hygiene needs but all the care plans reviewed showed additions of points relating specifically to the individual resident. Where residents had specific needs relating to them only, individual care plans are used, for example one resident who needed continuous oxygen therapy had a clear care plan relating to this, it was also cross-referenced to areas such as mobility and meeting personal hygiene needs. Care plans are regularly evaluated, showing changing needs and actions to be taken to meet these needs. Twenty five of the 28 residents who responded to that section of the pre-inspection questionnaire said that they felt Avon Court Care Centre D51_D01_S59517_AvonCourt_V243746_041005_Stage4.doc Version 1.40 Page 10 well cared for. All of the relatives who responded to that section of the reinspection questionnaire said they were satisfied with the overall care provided. Clear and detailed manual handling care plans are in place for all residents in both their individual files and in their rooms, these plans direct care. Prior to these plans being drawn up and detailed assessments take place. Where residents have complex manual handling care needs, the section of the assessment relating to the suitability of the resident’s bed is not always completed in full. This should always take place. The home does provide some variable height beds but care plans indicate that more are needed. The manager reported that since she took up post, she had identified this as an issue. An action plan is in place to purchase more variable height beds to meet the needs or residents with complex manual handling needs. All residents are assessed for risk of pressure damage. A review of assessments indicated that many of the residents were at risk of pressure damage. All of the assessments, apart from one, did include a full assessment of all risk factors. Where residents are assessed as being at risk of pressure damage, some have care plans in place to direct staff on how to reduce risk, others do not. The care plans that are in place do not detail all actions to be taken to reduce risk. Equipment is provided to reduce risk but a lack of care planning for some residents means that the home cannot provide evidence that it is being consistent in its approach to the prevention of pressure damage and residents thereby may have the potential to be placed at risk. This home has put extensive work into ensuring that clear records are in place for residents. All frequent care charts are now completed and daily assessments include fluid intake for residents, where indicated. The home now needs to concentrate on ensuring that they use more precise terminology when completing documentation on residents’ care needs. The home needs to avoid the use of wording such as “normal limits”, “aggressive” or “assist” as it does not accurately describe the resident’s presenting care needs. Precise, measurable terminology must always be used when completing residents’ documentation, to ensure that their actual nursing and care needs can be met. Records clearly show that regular contact with residents’ GP and other healthcare professionals such as the tissue viability nurse take place. All records relating to management of wounds are clear and wounds are regularly monitored. There is a very low incidence of wounds relating to pressure damage or skin tears in the home. Much work has been put into improving systems for the management of medication and the standard is now met in full. All records are clear and fully completed. Medicines are safely stored in an orderly manner and the home has set up systems for the disposal of medicines, which comply with recent legislative changes. Two registered nurses showed a detailed knowledge of the Avon Court Care Centre D51_D01_S59517_AvonCourt_V243746_041005_Stage4.doc Version 1.40 Page 11 actions of the medicines they were administering. Where a resident wishes to self-medicate, a risk assessment is in place, this is regularly evaluated. Where residents are prescribed drugs relating to care plans, for example the management of pain or a skin condition, this should be included in care plans, to ensure that the effectiveness of the drugs treatment is evaluated As well as improving care planning, much work has been put into further developing systems to ensure that residents’ privacy and dignity are met. All of the six relatives who responded to the pre-inspection questionnaire said that they could visit in private and 20 of the 28 residents who responded to that section of the pre-inspection questionnaire said that their privacy was respected. Staff were observed to be respectful and supportive towards residents, this included frail persons and those showing complex behaviours. One resident said that they appreciated the night staff respecting their wish not to be disturbed during the night, unless they asked. Twenty four of the 26 residents who responded to that section of the pre-inspection questionnaire said that staff treated them well. Staff, including newly employed staff showed an awareness of the importance of ensuring that residents wore their own clothes and the laundress reported that most clothes were named or that, by working with carers, she could promptly identify the owners. Avon Court Care Centre D51_D01_S59517_AvonCourt_V243746_041005_Stage4.doc Version 1.40 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 & 15 The home is developing its activities programmes to meet the wide range of residents in the home. Visitors are encouraged. Residents are supported in choosing how they wish to spend their days. Residents said that they liked their meals and that they had a choice. EVIDENCE: The home continues to develop its activities programme for residents. The activities coordinator has been supported by BUPA in extending her knowledge base. All residents have a full social care assessment and care plan completed. Daily records of activities are completed. Fourteen of the 26 residents who responded to that section of the pre-inspection questionnaire said that the home provided suitable activities. A skittles group was observed during the inspection. One of the residents who responded to the preinspection questionnaire said that the home had given them a “wonderful” birthday party. Many of the residents are very frail and the activities coordinator gives such persons 1:1 support. One resident said that bell ringers had visited the day before, which they had enjoyed. The visitors book showed that people felt able to come in and out of the home as they wished and several visitors were observed during the inspection. All of the six relatives who responded to the pre-inspection questionnaire said they felt welcomed into the home at any time. Avon Court Care Centre D51_D01_S59517_AvonCourt_V243746_041005_Stage4.doc Version 1.40 Page 13 It was observed that residents were encouraged to chose how they spent their lives. This was documented in care plans, which were followed by staff. For example on resident reported that some days they chose to stay in bed, this was documented in their care records. Residents were able to bring in items of their own into the home and many rooms reflected the individual’s likes and preferences. The home has two dining rooms, one on each floor. Both have been redecorated in attractive colours and new table-cloths and napkins provided. All residents spoken with said that they could choose what they ate. It was noted as good practice that at lunchtime one resident decided that they wanted a meal different from what they had ordered and staff gave the resident the meal they wanted. All residents are offered a choice of drinks with their meal. Meals are now given out in a much more organised manner and staff are available to support residents who need assistance to eat. The chef showed a good knowledge of the needs of residents. Twenty two of the 28 residents who responded to that section of the preinspection questionnaire said that they liked the food, five said they sometimes did and only one said that they did not. Considering that the home is providing meals for 55 residents, all of whom will have different preferences and tastes, this inspection shows how hard the home is striving to meet residents’ needs. One resident described the meals as “very, very good” and that their favourite was steak and kidney pie, another said that the kitchen “could not do anything better” and another resident who described the food as “very nice” also said “and I’m awkward with my food.” Avon Court Care Centre D51_D01_S59517_AvonCourt_V243746_041005_Stage4.doc Version 1.40 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 & 18i The home has a complaints procedure which works in practice. Systems are in place in the home to protect residents from abuse. EVIDENCE: All residents have information on the home’s complaints procedure provided to them in their room. All of the relatives who responded to the pre-inspection questionnaire said they were aware of the home’s complaints procedure. Twenty three of the 27 residents who responded to that section of the preinspection questionnaire said they knew who to talk to if they were unhappy about their care. The manager maintains full records of all complaints and concerns. The records show what actions have been taken to address complaints and concerns. Several residents spoken with said that if they were not happy with their care, they would bring it up initially with the nurse in charge of their floor and if they were still not happy, with the manager. One resident described the manager as “very approachable” The manager has experience of working within local vulnerable adults procedures. Since she has been in post, she has ensured that all staff have been given a copy of the local vulnerable adults procedure and is discussing this individually with the staff that she supervises, this will then be cascaded to all staff in the home. Twenty six of the 28 residents who responded to that section of the pre-inspection questionnaire said that they felt safe in the home and none said that they did not. Avon Court Care Centre D51_D01_S59517_AvonCourt_V243746_041005_Stage4.doc Version 1.40 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 22, 23, 24 & 26 Avon Court is well-maintained, clean and provides comfortable furniture and equipment to give residents a homely setting in which to live. Equipment to support disabled people is in place. Most systems for infection control are in place, however residents could be put at risk by a lack of awareness of certain principals from some ancillary staff. EVIDENCE: Avon Court has undergone a full up-grade during the past 18 months. All areas inspected were clean and well maintained. There is a maintenance book, to which all staff have access, which is regularly reviewed and up-dated by the maintenance manager. The maintenance manager showed a detailed knowledge of all areas which needed to be addressed in the home. Each floor of the home has one dining room and a choice of sitting rooms. There is an attractive paved outside garden area, which was being used by several residents and their visitors during the inspection. A range of assisted bathrooms and wcs are available to residents, as well as en-suites in their own rooms. All residents have individual rooms and they can bring in items of their Avon Court Care Centre D51_D01_S59517_AvonCourt_V243746_041005_Stage4.doc Version 1.40 Page 16 own if they wish. One resident described their room as “comfortable” and another as “lovely”. A range of equipment to meet the needs of persons with a disability are available. Staff were observed to be competent in using manual handling aids such as lifting slings. One resident with complex needs had had assessments made by a range of professionals and equipment relevant to their needs provided. Their records showed that this had been consulted with their relatives. The home has put extensive work into ensuring that staff respond promptly when residents use their call bells. It was observed that all residents had been left with access to their call bells and all of those residents who were able to communicate were able to tell the Inspector of how to use it. One resident said that staff “come immediately” and another that staff were “very good at attending” when they used their bell. Registered nurses and care staff showed a good knowledge of the principals of prevention of spread of infection and said that all equipment, including gloves, sterile gloves and dressings packs were provided. A copy of the local up-dated policy and procedure on infection control was available to staff. The inspection indicated that some ancillary staff need more support in understanding the principals of prevention of spread of infection. One sluice room had a clinical waste bin placed in it which was not foot-pedal operated, the bin had only been recently put in the room. The laundress appeared to be continuing to sort contaminated and potentially infected laundry, although this is not part of the home’s policies. All other systems for prevention of spread of infection in the laundry were safe. There is at least one sluice room on each floor of the home. One washer disinfector was beginning to show development of deposits in a few places under the lid of the machine and some lime-scale under the wash hand basin, these should be removed before they develop further. Avon Court Care Centre D51_D01_S59517_AvonCourt_V243746_041005_Stage4.doc Version 1.40 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 & 29 A full range of staff with a skill mix to meet residents’ needs are in post. Residents are supported by the home’s recruitment polices and practices. EVIDENCE: Avon Court is required to staff the home in accordance with a Condition of Registration set out by the Commission. They were meeting the requirements of this Condition. The majority of relatives who responded to the preinspection questionnaire said that in their opinion there were always enough staff on duty. Both floors of the home are managed by a senior registered nurse, supported by the deputy manager, who reports to the manager. Staff spoken with knew about residents’ needs in some detail. The files of three recently appointed staff showed that a full recruitment process is carries out and all files included copies of proofs of identity, two references, a fully completed application form and health questionnaire. Files are kept in an orderly manner. All staff have a CRB and pova check. Avon Court Care Centre D51_D01_S59517_AvonCourt_V243746_041005_Stage4.doc Version 1.40 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, 35, 36 & 38 Residents are protected by an experienced manager who has put many improvements in place in the home. The owners have a system in place to find out residents’ views and regular review of quality of care. Residents’ property is properly stored with full records in place. Residents are supported by staff who are regularly supervised. Systems to ensure the health and safety of residents and staff are in place. EVIDENCE: The manager is an experienced registered nurse and manager. She came into post in May 2005, having previously managed another BUPA home. BUPA regularly audits service provision in the home. Internal audits on care plans are undertaken regularly. The home has monthly visits from a BUPA manager and a report is completed. Since the previous inspection, an internal audit on meals provision and activities has been undertaken. Records of residents’ moneys are clearly maintained and regularly audited. All valuables handed in are properly documented and stored. Avon Court Care Centre D51_D01_S59517_AvonCourt_V243746_041005_Stage4.doc Version 1.40 Page 19 The manager has put in a full supervision and annual appraisal system for staff. A matrix is in place to ensure that the manager can review if all staff have had regular supervision. Supervision is provided in varied formats, depending on supervisee’s needs and service requirements. Records of individual supervisions are maintained, these are clear and supportive in tone. All records of maintenance to the home and equipment are clearly maintained, to show that systems to ensure Health and Safety are in place. The fire log book is properly maintained, showing the home is complying with requirements from the local fire brigade. The kitchen is kept in an orderly manner with all stocks properly stored. Staff are regularly trained in food handling. Avon Court Care Centre D51_D01_S59517_AvonCourt_V243746_041005_Stage4.doc Version 1.40 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 x 4 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 x 2 STAFFING Standard No Score 27 3 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 x 3 x 3 3 x 3 Avon Court Care Centre D51_D01_S59517_AvonCourt_V243746_041005_Stage4.doc Version 1.40 Page 21 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 8 Regulation 12(1)(a), 13(4)(a) (c), 14(1)(a) (2)(a)(b), 15(1)(2) (b)(c) 17(1)(a) 12(1)(a) 15(1)(2) (b)(c), 17(1)(a) 13(3) Requirement All risk assessments for pressure damage must include all factors relating to the service user. If the service user is assessed as being at risk of pressure damage, a full care plan must be in place to direct staff on how risk is to be reduced. Staff must use precise, measurable terminology, when drawing up care plans or assessing response to care plans. Ancilliary staff who have responsibility for areas relating to infection control must be trained in the importance of their role in the prevention of spread of infection. Timescale for action 31 December 2005 2. 8 31 December 2005 31 December 2005 3. 26 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 7 Good Practice Recommendations Manual handling assessments relating to the suitability of the service users bed or chair should always be completed D51_D01_S59517_AvonCourt_V243746_041005_Stage4.doc Version 1.40 Page 22 Avon Court Care Centre 2. 9 3. 26 in full. Where residents are prescribed drugs to support needs identified in care plans, a record of the drug used should be included in the care plan, to assist in evaluation of the effectivenss of the treatment. The beginning deposits of lime-scale on the under surface of the lid of one washer disinfector and the flooring under the wash hand basin should be removed before the deposits develop further. Avon Court Care Centre D51_D01_S59517_AvonCourt_V243746_041005_Stage4.doc Version 1.40 Page 23 Commission for Social Care Inspection Avonbridge House Bath Road Chippenham Wiltshire, SN15 2BB 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 Care Centre D51_D01_S59517_AvonCourt_V243746_041005_Stage4.doc Version 1.40 Page 24 - 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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