Inspection on 25/06/08 for Avon House

This inspection was carried out on 25th June 2008.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Avon House 11/07/07

Avon House 09/08/06

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOMES FOR OLDER PEOPLE Avon House Stockcroft Road Balcombe West Sussex RH17 6LG Lead Inspector Annette Campbell-Currie Unannounced Inspection 25th June 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 DS0000066866.V366160.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 DS0000066866.V366160.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Avon House Address Stockcroft Road Balcombe West Sussex RH17 6LG 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) 01444 811282 Avon House (Balcombe) Ltd Mrs Veronica Vivien Freeman Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Avon House DS0000066866.V366160.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th July 2007 Brief Description of the Service: Avon House is a care home for up to 19 elderly residents over 65 years of age. The registered manager responsible for the day-to day running of the home is Mrs Veronica Freeman. Avon House is a large Edwardian property located in a pleasant residential road in the village of Balcombe in West Sussex, with local shops a short distance away. Accommodation for people staying in the home is arranged on two floors with a passenger lift giving access to both floors. There is accommodation for staff on the second floor. Accommodation consists of thirteen single and three double rooms all with ensuite facilities. There is a large dining/lounge area on the ground floor. The home is surrounded by a large rear and front garden both of which are accessible to residents. The fees charged range between £356 and £575 per week. Avon House DS0000066866.V366160.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating of this service is One Star. This means that the people who use this service experience adequate quality outcomes. Annette Campbell-Currie carried out the site visit over four and three quarter hours. The registered manager was on leave at the time. The newly appointed deputy manager was running the home in the manager’s absence. The deputy manager assisted us (the Commission) with our inspection. The office containing documents required for inspection was locked and no one in the home had access to it. The deputy manager made available the documents and records that she had access to, however a number of documents were kept locked in the office and she did not have a key. There were sixteen people staying in the home at the time; two were out for the day with relatives. The manager had completed an annual quality assurance assessment form (AQAA) before the inspection and this provided some information that was used in the planning of the site visit. During the visit three people living in the home were spoken with at length and three members of staff including the deputy manager. The gardens, communal areas and three bedrooms were seen. The following documents were read: the case records of three people living in the home, the record of complaints, duty rotas, some health and safety records, the medication records and the storage arrangements for medication were seen. Surveys had been sent out to people living in the home, staff and healthcare professionals to find out what people think about the home. Replies were received from six residents, six members of staff and a healthcare professional. The responses to the surveys were positive and the information gathered has been used to help make an assessment of the service. It was not possible to fully assess seven of the thirty-eight standards because not all the information required was available (standards 18, 29, 30,31, 33, 35 and 38). A judgement has been made with the available evidence. The outcome for people living in the home has been assessed in relation to twenty-one of the thirty-eight National Minimum Standards for the care of older people, including those considered to be key standards to ensure the welfare of people living in the home. Five requirements have been made following the site visit and an improvement plan has been requested. What the service does well: Avon House DS0000066866.V366160.R01.S.doc Version 5.2 Page 6 The people who returned surveys and those spoken with on the day were very happy with their care. People said the staff listen and understand their needs and one person said: “this is an excellent home and staff are very good, I could not have chosen better”. The home is comfortable and kept clean and hygienic. Food is cooked on the premises and people said that they enjoy the meals; one person commented that: “the food is excellent”. There is a small staff team that work well together so that people live in a relaxed and pleasant atmosphere. The communication between staff is good and details of care at night and during the day is passed to people on the next shift at handover sessions. What has improved since the last inspection? What they could do better: The records specified in Regulation 17 of the Care Standards Act 2000 should be available for inspection and the effective day-to-day running of the home by the person in charge. A requirement has been made regarding this matter. Care plans should provide clear guidance to staff about the way that personal and healthcare should be provided so that people’s needs are fully understood and their needs monitored. Care plans should be reviewed monthly to ensure that people are receiving the care that they need. Risk assessments should be carried out where a specific need is noted for example for people who walk independently to the village and those who smoke. There should be risk assessments and lockable facilities for people who hold their own medication. The procedure for administering medication should follow the guidelines set out by the Royal Pharmaceutical Society. A requirement has been made regarding this matter. Staff in charge of the home should be made aware of the reporting policy and procedure regarding safeguarding vulnerable people should there be a concern that abuse may have occurred or an allegation made. A requirement has been made regarding this matter. Avon House DS0000066866.V366160.R01.S.doc Version 5.2 Page 7 The advice of the environmental health officer should be sought with regard to the fitting of window restrictors to make sure that there is no risk of people falling out. A requirement has been made with regard to this matter. Substances hazardous to health should be kept in a locked facility to ensure that people are protected from the risk of harm. A requirement has been made with regard to this matter. An up to date insurance certificate should be displayed so that people know that they are fully protected. 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 DS0000066866.V366160.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 House DS0000066866.V366160.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Avon House does not provide intermediate care. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. It was not clear that people always have their needs assessed before a decision is made about them moving to the home. EVIDENCE: The deputy manager said that the manager carries out all the assessments before people move to the home. The deputy manager said that she is due to have some training so that she will have the knowledge and skills to carry out the pre-assessments. A standard format is used that covers all aspects of the person’s background and needs. It was not clear that people were asked what name they prefer staff to use when they address them. Samples of three case records were seen including the records for two people who had moved to the home recently. One person had moved in February but the assessment had not been completed until March. The deputy manager said Avon House DS0000066866.V366160.R01.S.doc Version 5.2 Page 10 that another person who moved from a different area had an assessment when she visited the home for lunch. One person’s medical history had not been completed. Assessments carried out by social workers were on case files to ensure the home had the information needed before the person moved. The manager said in the AQAA that people are welcome to visit the home before they make a decision to move. This had been the experience of someone who had recently moved. There was a space on the assessment form for people to sign to say that they agreed with the assessment. Avon House DS0000066866.V366160.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Most health and personal care needs are set out in a care plan. People’s healthcare needs are usually met. The medication procedures do not fully protect people living in the home. People are treated with respect and their right to privacy upheld. EVIDENCE: There is a standard format for assessment and care planning. Three people’s care plans were read and only one had a photograph of the person attached to the records. A further recommendation has been made regarding this matter. Care needs were noted however the guidance for staff about the way to support individuals was not clear in all cases; for example it was noted that one person likes to be independent with personal care and that staff should observe, however the deputy manager explained that staff do need to support this person at times and sometimes they need to use creams to protect the person’s skin and this was not noted. Avon House DS0000066866.V366160.R01.S.doc Version 5.2 Page 12 Risk assessments had been carried out to identify the level of risk in aspects of people’s lives including mobility. The guidance for staff to help prevent risks was not clear in some cases for example where behavioural issues were noted staff should be provided with guidance about ways to support the person. There were some areas of possible risk that had not been assessed for example for people who walk independently to the village and another person who smokes. In order for people to be supporting in maintaining their independence assessments should be carried out so that risks can be minimised. Care plans had been reviewed however reviews had not been carried out monthly to ensure that people’s needs are monitored frequently and any changes noted. Health care needs were documented and visits from the GP or district nurse logged. Contact from the incontinence nurse was also noted. People have their weight checked monthly and one person had had a review with their GP in April. There was no clear guidance regarding the dietary needs of one person who has a special requirement due to diabetes. It was not clear what special arrangements are made to assist a person with a visual impairment or that a risk assessment had been carried out on her room or access to the rest of the building. Staff had not received any special training or guidance about ways to support this person with their independence. The daily recording sheets were detailed and it was clear that staff communicate well about people’s changing needs. The deputy manager explained the care in place for the people whose care plans were read however the detail was not documented in all cases. The people who returned surveys indicated that they receive the care that they need and people spoken with also said this. Although staff on duty were clear about how to meet people’s needs guidance should be documented to ensure that all staff are clear about what is required of them. The deputy manager said that all staff have received training in administering medication although there were no records available to evidence this. The deputy manager said that Mrs Freeman provides the training, it was not clear what training she had undertaken to provide medication training for staff. Most people in the home have their medication administered by staff. One person holds paracetamol in her room for use as required; it was not clear that the medication is kept in a lockable facility for safety. Another person holds her own insulin that can also be kept in a fridge in the medication cupboard. There were no risk assessments for people who hold their own medication. There were no records to show that the temperature of the medication fridge was being monitored. The dispensing of medication should meet the guidance set out by the Royal Pharmaceutical Society. A requirement has been made with regard to this matter. The recording of controlled medication was also discussed with the deputy manager. There were photographs between the Avon House DS0000066866.V366160.R01.S.doc Version 5.2 Page 13 medication charts but they did not have the name of the person on them; this could lead to an error if the sheets in the folder were to be moved. People said that staff treat them well and staff on duty during the day were observed to be communicating well with people and providing support and care in a sensitive and calm manner. Avon House DS0000066866.V366160.R01.S.doc Version 5.2 Page 14 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): 11, 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People receive the lifestyle they choose in the home. People are supported to maintain contact with their family and to be involved in community activities. People are able to make some choices in their lives. People are provided with a balanced and nutritious diet. EVIDENCE: The care plans that were seen including some information about the things that people enjoy doing in their leisure time. There is a programme of activities that take place for an hour two days a week. An activities organiser comes to the home on these days. One person has been supported to borrow talking books from the mobile library and there are a number of books available in the home. The manager said in the AQAA that musical afternoons are arranged twice a month. A small groups of people play scrabble or cards and a bridge group was being formed. A group of people from the village hold a bible discussion group for women on Monday mornings. On the afternoon of the visit a birthday party was to be held for one of the people living in the home. The deputy manager said that most people have the opportunity to go out with Avon House DS0000066866.V366160.R01.S.doc Version 5.2 Page 15 relatives however some people do not have family to take them out. There is no transport available in the home for outings apart from staff cars. Two of the people spoken with said that they are involved in community activities including attending church, the Women’ Institute and another club that is run in the village. People are free to go out independently if they are able to however there were no risk assessments to make sure they would be safe and know what to do in an emergency. People are supported to maintain contact with their relatives and friends. People spoken with said that their visitors are made welcome in the home. People are supported to make some choices in their lives for example they can get up when they choose and go into the village if they are able to. A cook has been appointed recently. A care assistant was cooking lunch at the time of the visit as the cook had a day off. She said that she enjoys cooking and does not carry out care duties on the days that she is in the kitchen. The deputy manager said that staff have attended food hygiene training although there were no records available to show that this is the case. People spoken with said they enjoy the food and that they could have a choice of meal if they ask. The menu was displayed on a blackboard in the dining room although there was no alternative meal offered. Special diets and dislikes are catered for. Meals are taken in a pleasant dining area; people can also choose to eat in their rooms if they wish to. Avon House DS0000066866.V366160.R01.S.doc Version 5.2 Page 16 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 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People can be confident that their complaints will be listened to. The procedures for safeguarding people in the home do not fully protect people. EVIDENCE: There is a complaints policy that is displayed in the hallway. The policy needs to be updated to show the current contact details for the Commission. The three people who returned surveys said that they know how to make a complaint. People spoken with said they know who to talk to if they have any concerns and they feel they would be listened to. There is a system for recording complaints; six have been recorded in the past twelve months. The complaints had been investigated however one person had raised an issue that should have been referred to the Caring and Social Services in line with the West Sussex multi disciplinary safeguarding policy and procedure. The deputy manager said that staff have had training in adult abuse however there were no records available to show that this is the case. The people in charge of the home were not clear about reporting procedures in line with the West Sussex safeguarding policy should there be a concern that abuse may have occurred or an allegation made. A requirement has been made regarding this matter. Avon House DS0000066866.V366160.R01.S.doc Version 5.2 Page 17 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, 23 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People live in a home that is clean, pleasant and hygienic. The home is well maintained however there are aspects of the environment that could present a risk to the welfare of people living there. EVIDENCE: The home is pleasantly furnished and people are able to personalise their rooms. There is adequate communal space and people now have access to the gardens by using a ramp that has recently been built. There is a patio area in the garden and the deputy manager said that the home is planning to purchase sun umbrellas to provide shade so that the patio can be used in hot weather. Avon House DS0000066866.V366160.R01.S.doc Version 5.2 Page 18 Someone is employed to provide day-to-day maintenance of the home and the AQAA states that all equipment including fire equipment is serviced as required. Improvement and development plans for the building were not available. People spoken with said that they like their rooms however none of the bedrooms have locks to provide privacy. The rooms that were seen did not have window restrictors; no risk assessments had been carried out to make sure people were not at risk of falling out. The manager is advised to seek guidance from the environmental health officer regarding the fitting of window restrictors. A requirement has been made regarding this matter. Door closures have been fitted to internal fire doors. Currently one bathroom is in use and the second bathroom is still being used for storage. There are two steps to the part of the corridor where the bathroom is located; we were told that this is difficult for some people who have mobility difficulties and have rooms on the first floor. This matter was discussed with the manager at the last inspection and she was advised to make both bathrooms available for use. The laundry facilities are suitable for the needs of the home and care staff are responsible for laundry duties. There are no lockable facilities for chemicals that may be hazardous to health and a number of these items were being stored on open shelves in the laundry room which is accessible to people living in the home. The chemicals were moved during the afternoon to a safe location however a more permanent solution should be found to make sure that people are kept safe. A requirement has been made regarding this matter. A member of the care staff was responsible for cleaning duties during the visit and the home was clean with no unpleasant odours. Avon House DS0000066866.V366160.R01.S.doc Version 5.2 Page 19 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 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The numbers and skill mix of staff meets people’s needs. There were no recruitment records available to show that the recruitment process is robust. There were no training records available to show that that all staff have attended the required training. EVIDENCE: At the time of the visit there was a senior carer and a care assistant on duty. The manager was away on holiday for three weeks and the deputy manager had come in to deliver some shopping; she was not on the duty rota as she was due to be on waking night duty at eight o’clock. A member of the care team was providing lunch as the cook had a day off and a carer was on cleaning duties. Three care staff live in a flat on the second floor and the deputy manager said that there is an understanding that one person will be available at all times to provide cover in an emergency. One person is on waking duty at night and one of the staff in the flat is on sleeping in duty, the deputy manager said this provides sufficient cover to meet people’s needs. The deputy manager said that 90 of her time is spent providing care which means that it is difficult to carry out administrative tasks when she is in charge of the home. Avon House DS0000066866.V366160.R01.S.doc Version 5.2 Page 20 The manager said in the AQAA that three of the seven permanent staff have achieved the National Vocational Qualification (NVQ) at level 2 or above and three people are studying for the award. The deputy manager has been in post since January and she is now studying for the registered manager’s award. The manager said in the AQAA that she is also registered to study for this award. There were no recruitment records available for inspection. The three staff who returned surveys said that all the required checks had been carried out as part of their recruitment. The manager said in the AQAA that required checks including Criminal Record Bureau (CRB) checks have been carried out for all newly recruited staff. The staff spoken with said they had received the training that they require. The staff who returned surveys said that they had the induction and training they needed to do their job. There was a notice about planned training on the staff notice board however there were no training records available to show that people had attended the mandatory training. Avon House DS0000066866.V366160.R01.S.doc Version 5.2 Page 21 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 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. An experienced manager runs the home. The procedures for listening to the views of people living in the home were not clear. Records of procedures for protecting people’s money were not available. The health, safety and welfare of people living in the home are not always protected. EVIDENCE: Mrs Freeman is an experienced manager and has registered to study for the registered manager’s award. People who returned surveys and those who were spoken with were happy with the way the home is run. The manager should ensure that the person left in day-to-day charge of the home in her absence Avon House DS0000066866.V366160.R01.S.doc Version 5.2 Page 22 has access to the records required for inspection and for the efficient running of the home. A requirement has been made regarding this matter. The manager said in the AQAA that quality satisfaction surveys are sent out to residents and relatives. The results of the surveys were not available to show that any issues raised had been addressed. The manager said that meetings are held for residents and staff. The deputy manager said that some people are supported with their day-today finances through a petty cash system but she did not have access to the records to show that the system is robust in order to protect their finances. The home has employed a company to provide consultancy for health and safety management. There were two environmental matters noted during the visit that could present a risk to people living in the home; there were no window restrictors in some bedrooms and chemicals hazardous to health were not being safely stored. Requirements have been made with regard to these points. There were no training records available to show that mandatory training is up to date although staff said they have attended training sessions. The insurance certificate on display was out of date; a current certificate should be displayed so that people can be sure that they are adequately protected. Avon House DS0000066866.V366160.R01.S.doc Version 5.2 Page 23 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 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 2 X X 2 Avon House DS0000066866.V366160.R01.S.doc Version 5.2 Page 24 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 OP9 Regulation 13,17 Requirement The guidelines set out by the Royal Pharmaceutical Society for the administration of medication should be followed and people should be supported to administer their own medication within a risk assessment framework. The manager should ensure that records are available at all times for inspection in the care home and for the efficient running of the service by the person in charge. Measures must be taken to ensure that staff in charge of the home are aware of the reporting procedures regarding safeguarding matters to ensure that people are fully protected. Timescale for action 31/07/08 2 OP37 17 (3) (b) 31/07/08 3 OP18 13 (6) 31/07/08 4 OP38 13 (4) (a) The advice of the environmental health officer should be sought 31/07/08 with regard to the fitting of window restrictors to prevent the risk of people falling. Avon House DS0000066866.V366160.R01.S.doc Version 5.2 Page 25 5 OP38 13 (4) (c) Substances hazardous to health should be stored in a lockable facility in order to keep people safe. 31/07/08 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 OP7 Good Practice Recommendations Residents ‘ plans of care to include a photograph as specified in regulation 17, Schedule 3. Avon House DS0000066866.V366160.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 DS0000066866.V366160.R01.S.doc Version 5.2 Page 27 - 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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