Inspection on 15/07/08 for Avon House

This inspection was carried out on 15th July 2008.

CSCI found this care home to be providing an Good service.

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 House 20/04/10

Avon House 09/07/07

Avon House 23/05/06

Avon House 13/12/05

Avon House 19/01/05

Avon House 17/05/04

Similar services:

Ashlong House

Spring Lane Care Home

Avenues (The) (Neave Crescent)

Barrington Lodge Nursing Home

Beacon House Nursing Home

St Mary`s Convent & Nursing Home

1-3 Frederick Gardens

The Royal Star and Garter Home

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Avon House Allen Street London W8 6BL Lead Inspector Ann Gavin Key Unannounced Inspection 15th July 2008 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 House DS0000026012.V368460.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 House DS0000026012.V368460.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Avon House Address Allen Street London W8 6BL 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) 020 7937 3307 020 7795 6288 avon.house@craegmoor.co.uk London Parkcare Limited Grace Corriea Care Home 35 Category(ies) of Physical disability (35) registration, with number of places Avon House DS0000026012.V368460.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home with nursing - Code N to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Physical disability - Code PD The maximum number of service users who can be accommodated is: 35 9th July 2007 Date of last inspection Brief Description of the Service: Avon House is a purpose built home, managed by Craegmoor Healthcare, that provides accommodation and nursing care for up to 35 older people. The home is close to the shops and transport links of Kensington High Street. Residents’ bedrooms are located on all three stories in the home, with lift access to the upper floors. On the ground floor there is an open plan lounge, a large dining room, the main kitchen, a conservatory, the manager’s and administration offices. There are individual small lounges and dining areas on the first and second floors. The home has twenty-six single and four double bedrooms, all with en suite facilities. To the front of the home there is limited off street parking, and a small garden to the rear. Avon House DS0000026012.V368460.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This unannounced key inspection took place on Tuesday 15th July 2007 from 10:00 – 17:00. During this visit time was spent talking with people living in the home, the deputy manager and nursing and care staff on duty. Questionnaires were sent out to all the people who live in the home to 20 relatives and 10 other professionals. There were two relatives and one other professional surveys returned. The care of three people living in the home was reviewed by talking with them and staff responsible for their care and checking care records. The manager was away from the service and the deputy manager has not long been in post so the Area manager arrived and stayed for the inspection. The inspector spoke with the manager of the home on the telephone the day after the inspection. What the service does well: What has improved since the last inspection? The home now has person centred care plans for all of the people living in the home. The manager is working, with the staff, towards accreditation to the GSF Golden Standard Framework Award which is concerned with helping people to live well until the end of life and includes care in the final year of life for people with any end stage illness. Avon House DS0000026012.V368460.R01.S.doc Version 5.2 Page 6 Avon House is undergoing a major refurbishment of all the bedrooms, communal areas including furniture and fittings. New radiators and improved heating is being installed. The courtyard garden has become accessible to wheelchair users through the laying of a paved area throughout. 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. The summary of this inspection report can be made available in other formats on request. Avon House DS0000026012.V368460.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Avon House DS0000026012.V368460.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People have an assessment of their needs prior to moving into the home. Prospective residents are given the opportunity to spend time in the home. The home does not provide intermediate care and key Standard 6 does not apply. EVIDENCE: Tracking the care of three people who live in the home showed that each person had their physical, social, cultural and religious needs assessed prior to being admitted to the home. The deputy manager explained that the assessments are carried out by the home manager and himself. This follows referrals from the PCT (Primary Care Trust), Social Services or individuals. Both the PCT and social services complete a full needs assessment as part of their referral. The home has their own comprehensive assessment which they Avon House DS0000026012.V368460.R01.S.doc Version 5.2 Page 9 then complete for all prospective residents. The assessments seen, completed by the home were clear with good information. The deputy manager talked through the process for a recent assessment they had made. The prospective resident had visited the home and seen a vacant room which they will now be moving into. The home’s Statement of Purpose was displayed on the notice board in the entrance hall. It is specific to Avon House and accurately describes the services provided. There were contracts on one of the residents files looked at. The administrator explained and was later confirmed by the manager that one contract was being revised due to three parties being involved in the funding and the other one was with a relative to sign. Avon House DS0000026012.V368460.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are involved in planning their own care. Care plans are person centred and cover all aspects of peoples lifestyles and healthcare needs. EVIDENCE: ‘I like my mouth care done daily…’ Extract from care plans ‘I cannot care for myself at the moment.. I like…’ ‘Staff have always made sure curtains are drawn and the door closed when giving our relative personal care’ Extract from relatives questionnaire. The three care plans seen were all person centred and were written with the person, and or their relatives, when appropriate. There was a section on all Avon House DS0000026012.V368460.R01.S.doc Version 5.2 Page 11 aspects of life. Beginning with a photo of the person their name and how they wish to be addressed. A section on ‘people who are important to me’ is followed by ‘things that are important to me’. The section continues giving a clear picture of the person, the reason for admission their key needs, how they wished to be supported and their life story. The care plans also contain excellent health promotion with a wide range of assessments. On admission people have a full assessment of all areas of healthcare including the need for any pressure relieving mattresses. Speaking with staff they were clear about their role and talked of the ways in which they supported residents. One of the relatives questionnaires made the following suggestions in answer to the question ‘how can the service improve’ ‘ make sure alarm bells and drinks are in easy reach of patients sometimes when we visit they are out of reach’ Medication and MARs (medication administration records) records were checked on one floor and were found to be well kept and recorded. There was an audit from the local pharmacist being carried out during the day. The feedback from the deputy manager was that the pharmacist had found all in order. The manager is working, with the staff, towards accreditation to the GSF Golden Standard Framework Award which is concerned with helping people to live well until the end of life and includes care in the final year of life for people with any end stage illness. Avon House DS0000026012.V368460.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are able to be involved in daily activities of their choice. Friends are family are made to feel welcome. There is a full time chef who prepares and cooks fresh food daily. EVIDENCE: ‘Service users have detailed activity plans within their person centred care plan Activities are tailored to the needs and wishes of the service users, as detailed in the care plans, visiting pastoral care’ We have ‘Open Door’ policy for visitors, local community groups invited (Extract from the managers Annual Quality Assessment) ‘Staff always take care not to interrupt during our visit…. Staff encourage us to take our relative out. They are always ready on time and staff are flexible about our return’ (Extract form relative’s questionnaire) Avon House has a full time activities organiser who works Monday to Friday. Speaking with them they talked through the activities that they plan together Avon House DS0000026012.V368460.R01.S.doc Version 5.2 Page 13 with the people who live in the home. In the morning the activity organiser visits people individually helping them with their mail, talking, and giving a hand massage. Each afternoon there are planned activities for those people who wish to take part. These included film shows, quizzes, and baking. The baking involves taking part in creaming and whisking ingredients to make a large cake which all share for that afternoon tea. On the day of the inspection people were observed playing board games in the enclosed garden area. The afternoon continued with singing and gentle exercises with a soft ball. The organiser spoke of the volunteers they have who help with the activities specifically any outings. The organiser is currently going through the CRB (Criminal Record Bureau) checks for each volunteer. There does not appear to be any systematic training or formalise policy and procedures in place in the home for volunteers. This needs to be acted upon to ensure the safety of residents at all times. There are contacts with the local community and the manager is currently talking with a local firm who wish to offer volunteers to support residents on a regular basis. There is a hairdresser who visits every two weeks. The home had recently held a BBQ and another was planned for the following week. Those people who wish to attend any religious services are encouraged and supported to attend. The organiser said that the residents lead with ideas for outings or activities. Some of the examples quoted were a visit to the Japanese gardens or to Holland Park or Hyde Park. Avon House does not have their own transport so use is made of taxis or dial a ride. The manager noted on their annual quality assurance assessment ‘More activity training for staff as well as activity organiser, increase links in the community’ The chef spoke of the menu planning and the comments book, which is left, for all to fill in. The book contained very good comments. Though one of the comments received from a relative was’ sometimes meals arrive cold and are not what is stated on the menu.’ The chef explained that they do very little frozen food with the exception of ice cream. All other foods are bought on a daily basis to ensure freshness and are cooked on the premised. There were two choices offered for lunch on the day of the inspection. The menu was written up on a board in the dining room. The staff said many residents enjoy having their breakfast in the small lounges situated on each of the floors. The majority of residents enjoy having their lunch in the main dining hall. During the day staff were observed offering frequent drinks to residents. Avon House DS0000026012.V368460.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has an open culture that allows residents to express their views and concerns in a safe environment. The staff understood safeguarding procedures. EVIDENCE: ‘..Complaints procedures are displayed in the entrance hall, copies of the procedure included in the information packs given to service users and representatives’ (Extract from the managers AQAA - Annual Quality Assessment) ‘If we have any concerns we feel we can always approach staff and management’ (Extract form relative’s questionnaire) The area manager talked through the procedures the home follows for any complaints. As per company policy all complaints received are sent to the area manager who will decide who should investigate. Since the last inspection there have been only two complaints which were dealt with within the timescales. Speaking with the manager the following day it was suggested that although Avon House DS0000026012.V368460.R01.S.doc Version 5.2 Page 15 there are not many complaints it would be good to note all ‘concerns’ and the actions taken so as to be able to monitor practice. One of the plans for the coming year that the manager noted in their AQAA is to make the complaints policy available in other formats. It was noted that the home receives a number of compliments and thank you cards which are displayed in the entrance hall. Staff interviewed during the inspection were clear about what the safeguarding policies are and what they would do in the event of any issue. The staff also confirmed that they have received safeguarding training. The financial records of three people who live in the home were looked at. Each person whose money is held by the home is kept and accounted for separately. The administrator holds these. The records were clear and correct. The list of valuable held for residents was also looked at. Avon House DS0000026012.V368460.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Avon House is a safe well maintained home. People who live in the home said they found it welcoming to themselves and their families. EVIDENCE: ‘A programme of redecoration is available and commencing in July.. Furnishings and lighting are of domestic and homely character and this will be replaced this year. We have two gardens which have upgraded and replanted…’ Extract from the AQAA (Annual Quality Assurance Assessment) completed by the manager. Avon House is a purpose built home, close to the shops and transport links of Kensington High Street. Residents’ bedrooms are located on all three stories in the home, with lift access to the upper floors. On the ground floor there is an open plan lounge, a large dining room, the main kitchen, a conservatory, Avon House DS0000026012.V368460.R01.S.doc Version 5.2 Page 17 the manager’s and administration offices. There are individual small lounges and dining areas on the first and second floors. The home has twenty-six single and four double bedrooms, all with en suite facilities. To the front of the home there is limited off street parking, and two small gardens one to the rear and one in the courtyard. The courtyard is a small attractive garden with raised flowerbeds that has recently undergone an upgrade. It is now completely accessible to wheelchair users with the addition of a paved area throughout. There is also a planned water feature which residents have yet to choose. A tour was made of all communal parts of the home, and some bedrooms with residents’ permission. Each bedroom has an ensuite shower, toilet and wash hand basin. The home is currently having new radiators installed. It was also preparing for a major refurbishment which begins on the 21st July and is expected to last three months. The area manager explained how as this refurbishment will involve all areas of the home they have employed a project manager to oversee everything and to ensure the minimum disruption for all the people living in the home. Apparently the people who live in the home are being consulted on the colour scheme and décor. The home employs domestic staff to do all the cleaning. The home was clean throughout although work was being undertaken. However both the first and more specially the second floor had an unpleasant odour. It is hoped that the replacement of all floor coverings will eradicate this. The AQAA completed by the manager states that All beds will have been replaced this year, specialist equipment is available where and when needed. Access to the physiotherapist can be arranged. The beds seen were attractive and height adjustable. Those beds with cot sides were well padded and had specific risk assessments for cot sides. Avon House DS0000026012.V368460.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All staff were clear regarding their role and what is expected of them. People using the service report that staff working with them know what they are meant to do, and that they meet their individual needs in a way that they are satisfied with. Supervision of staff needs to be formalised with fixed times and supervision contracts. EVIDENCE: ‘We do not use agency staff ... All new staff are processed through the recruitment department at the support centre who make sure all checks are carried out and completed’ Extract from the AQAA (Annual Quality Assurance Assessment) completed by the manager. ‘In general most of the staff are very friendly and responsive to patients needs. They encourage people to socialise and seem concerned about their well being’ (Extract from relatives questionnaire) ‘All the staff that I have worked with so far have demonstrated a good understanding of the client’s care plans’ (Extract from professional questionnaire) The area manager explained the recruitment process. The organisation tries to use the local press to advertise. Applicantion forms and interviews are held in Avon House DS0000026012.V368460.R01.S.doc Version 5.2 Page 19 the home. The organisation is working to include residents in the interview process. This is currently done after they show prospective staff around the home they ask residents for an informal feedback. All the requests for references and CRB checks (Criminal Records Bureau) is handled by the homes head office. Since the last inspection the area manager now will see all CRB checks if they have any disclosures and will make the any decisions. The deputy manager said that there were always three qualified nurses and five carers on during the day and two qualified nurses and three carers on at night. The home has adopted the 12 hour shift pattern from 8 am to 8pm. This was discussed with the area manager and the reservation that it could be difficult for staff to maintain quality care on such long shifts and whether it was in the residents’ best interest. The area manager said he felt it promoted continuity for residents. It is recommended that the shift hours be reviewed in relation to the residents needs. On the day of the inspection the staff on duty was as stated on the staff rota. The home demonstrates a commitment to staff training. All of the care staff have an NVQ (National Vocational Qualification) level 2 and some are currently working on gaining an NVQ level 3. The area manager explained the training matrix which highlights when staff are due for their mandatory training. The home uses a mixture of their in own and outside agencies to delivery the training programme for the staff. Three staff were interviewed. They all confirmed that they received structured induction into their post and had regular training. They all commented on how much they learn in the home both form their peers, the managers and the residents. The interviews of staff and observation of practise showed that staff were clear about their roles and the support they offer to the people who live in the home. Avon House DS0000026012.V368460.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,37,38, Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who live at Avon house benefit from having a qualified and experienced manager who is committed to ongoing training for themselves and the staff team. There is a qualified deputy manager and a stable team of nursing, care and ancillary staff who are also experienced. EVIDENCE: ‘The company’s Quality Assurance programme is ongoing. The company has developed its own Clinical Governance department which supports and audits care delivery. Comment cards are provided for visitor’s feedback. Company policies and procedures are regularly reviewed and cascaded down to appropriate staff’ Extract from the AQAA (Annual Quality Assurance Assessment) completed by the manager. Avon House DS0000026012.V368460.R01.S.doc Version 5.2 Page 21 ‘The manager is easy to approach’ Quote from staff interview ‘I am happy here the staff and the way the home is run is all good’ Quote from resident interview ‘The manager in particular has shown that her door is always open and she always has time for both the staff and the client’s needs’ (Extract from professional questionnaire) The home’s registered Manager is a qualified nurse and she has also completed her NVQ Level 4 registered manager’s qualification training. In her annual assessment she also states that she has ...’completed a leadership skills course with the Department of Health in conjunction with Royal College of Nursing also am implementing the G S F W and RGN..’ There are monthly quality audits that the manager needs to complete and send through to the head office. This ensures an overall view of the service. The organisation also holds yearly clinical audits. Talking with staff and looking at their records demonstrated that there is no formal supervision of staff in place. The manager must formalise supervision for all staff with fixed dates and supervision contracts to facilitate and the staff’s and the residents they support. A selection of health and safety records were checked during the inspection. . They were up-to-date, showing that equipment is regulaly serviced and checked. The fire equipment was serviced in February this year. The Fire Risk Assesssment Plan was also seen. The maintence manager showed the records and explained the weekly maintenance checks they undetake. All the records up to 23rd June were held in one file the records after that were held separetly by the maintence amnager. The recording of Health and safety checks should be made in the designated record sheet so as to ensure compliance. Avon house has a policy for managing residents’ money, valuables and financial affairs. The administrator manages the records of those residents who require assistance with managing their money. A safe is available in the home for safekeeping and records of all transactions maintained. The records seen were clear and well kept. Avon House DS0000026012.V368460.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 3 3 Avon House DS0000026012.V368460.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No 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 OP29 Regulation 18 Requirement Timescale for action 30/09/08 2 OP36 18 The manager must ensure that the home have a policy, procedures and training for all volunteers to ensure the safety of residents at all times. The manager must formalise 31/08/09 supervision for all staff with fixed dates and supervision contracts to facilitate and the staff’s and the residents they support. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3 4 Refer to Standard OP16 OP27 OP37 OP37 Good Practice Recommendations A record of any ‘concerns’ could be kept with the action taken so as to be able to monitor practice. It is recommended that the shift hours be reviewed in relation to the residents needs. The recording of Health and safety checks should be made in the designated record sheet so as to ensure compliance All records need to be kept at all times in the home to DS0000026012.V368460.R01.S.doc Version 5.2 Page 24 Avon House ensure access to staff and for inspection. Avon House DS0000026012.V368460.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Avon House DS0000026012.V368460.R01.S.doc Version 5.2 Page 26 - 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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