Inspection on 30/11/06 for Avon Lodge

This inspection was carried out on 30th November 2006.

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 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 Lodge 09/10/07

Avon Lodge 31/05/06

Avon Lodge 19/12/05

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

CARE HOMES FOR OLDER PEOPLE Avon Lodge 33 Bridgend Road Enfield Middlesex EN1 4PD Lead Inspector Susan Shamash Key Unannounced Inspection 30th November 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Avon Lodge DS0000062486.V317464.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 Lodge DS0000062486.V317464.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Avon Lodge Address 33 Bridgend Road Enfield Middlesex EN1 4PD 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) 019 9271 1693 019 9271 1693 Avon Lodge UK Ltd Mr Rakesh Mathur Care Home 36 Category(ies) of Dementia - over 65 years of age (36) registration, with number of places Avon Lodge DS0000062486.V317464.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st May 2006 Brief Description of the Service: Avon Lodge is a residential care home for up to 36 older people over the age of 65 who may have a diagnosis of dementia. The property is a detached, two-storey, purpose-built property. All rooms include wash hand basins but they do not include en suite facilities. Rooms are provided on two floors accessed by a shaft lift and stairs. Each floor has two sets of bathrooms equipped with bath hoist facilities or easy access walk in showers. Communal space is provided in separate sitting, dining and recreational areas as well as a designated smoking area. A large garden area is also provided to the rear of the building. The stated aims of the home are to ‘provide a pleasant, comfortable and stimulating environment, conducive to meet the physical, emotional, cultural and religious needs of each resident, and homely surroundings to the best of their abilities. Residents are also encouraged to be independent wherever possible, and involve themselves in the decision-making process, relating to the daily living-arrangements in the home.’ The home is situated not far from shopping facilities and amenities in Enfield. A number of bus routes serve the area. As of November 2006, weekly fees range from £475 to £525. Current CSCI inspection reports are available for residents and relatives to see from the manager’s office at the home. Avon Lodge DS0000062486.V317464.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection visit lasted approximately seven and a half hours. The inspector was assisted by the registered manager for the home, who cooperated fully with the inspection process, and enabled the inspector to move freely about the home. The inspector spoke to approximately eight residents, three relatives and seven staff members (following their handover meeting). The inspector also had the opportunity to sample the evening meal served to residents. Written feedback forms were received from ten relatives, eight care managers, one health care professional and two residents. A tour of the home was conducted, and staff, residents’ and a range of other records maintained at the home were inspected. What the service does well: The home is well decorated following a major refurbishment and is bright and inviting. There is generally a high standard of furnishings, decoration and cleanliness in the home, and the home is well equipped to meet residents’ needs. Detailed assessments are undertaken before residents are admitted to the home and care plans are reviewed regularly to ensure that they are up to date. Residents are encouraged to maintain contacts with their friends and relatives. There is an open atmosphere within the home so that managers and staff are readily available to talk to relatives and residents. Residents and relatives speak highly of the support provided by staff at the home and their professionalism and the caring environment that has been produced. A thorough recruitment system is in place to protect residents and staff are generally well qualified, with 50 trained to at least NVQ level 2 in care. Health and safety records are maintained to a high standard at the home so that residents are protected appropriately. The home is well managed with clear policies and procedures regarding its operation and clear systems in place to protect residents from abuse. The home provides sensitive and effective support to residents who have challenging behaviour. Avon Lodge DS0000062486.V317464.R01.S.doc Version 5.2 Page 6 The manager is very experienced in working with residents who have dementia and relatives speak highly regarding the support he provides to them, particularly when residents are newly admitted to the home or unwell. What has improved since the last inspection? What they could do better: Regular review of risk assessments is needed to ensure that residents are protected appropriately. More activities should be made available to residents who do not join in group activities to ensure that they receive sufficient stimulation. Records of food eaten must include more choices including cultural alternatives provided to residents. A schedule for the redecoration of bedrooms, where paintwork is worn away by furniture, must be produced. There is a need for more carpet cleaning to ensure that there are no offensive odours in the home. Avon Lodge DS0000062486.V317464.R01.S.doc Version 5.2 Page 7 Induction records must be available for all new staff and more frequent staff supervision sessions and staff meetings are needed. Further training must be provided in first aid, challenging behaviour, fire safety and care planning, in addition to more dementia training for staff. The record of valuables stored on behalf of residents must specify the location where valuables are stored. It is recommended that a further COSHH cupboard (for hazardous chemicals) be provided on the first floor of the home, that a larger and better equipped staff room be provided and that the number of staff working in the home on the early shift be reviewed to ensure sufficient cover for laundry duties and activities. It remains recommended that an alternative format be considered for the service users guide and home menus to assist residents in making choices. Finally it is recommended that the staff application form should be updated and that further guidance regarding restraint be available to staff members. 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 Lodge DS0000062486.V317464.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 Lodge DS0000062486.V317464.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): 1, 3 and 5 (Standard 6 is not applicable as intermediate care is not provided). Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their relatives have the opportunity to visit the home, and their needs are assessed before they move in, to ensure that these can be met. Detailed information about the home is available to prospective residents so they can make an informed decision. EVIDENCE: A detailed statement of purpose and service users guide are available for the home as appropriate. However it remains recommended that an alternative format be considered for the service users guide that may be more accessible to residents who are diagnosed with dementia. Assessments in residents’ files indicated that a detailed assessment of residents’ needs takes place prior to their admission. This was confirmed by residents, relatives and staff spoken to. Residents and relatives spoken to indicated that there had been opportunities to visit the home prior to admission. Avon Lodge DS0000062486.V317464.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 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ health, personal and social care needs have been assessed and care plans are in place for each resident to ensure that these are met. Appropriate administration and recording of medicines ensures that residents’ medication needs are fully met. Residents and their relatives feel that they are treated with respect and consideration by the staff team. EVIDENCE: Four care plans were inspected and these were found to be detailed with regular monthly reviews as appropriate. Residents and relatives spoken to told the inspector that they were involved in choosing preferred care routines as appropriate. This consultation was recorded on care plans as appropriate in the form of residents’ or their relatives/advocates’ signatures. An appropriate level of detail was included within monthly reviews of care plans. Risk assessments had been undertaken for all residents including Avon Lodge DS0000062486.V317464.R01.S.doc Version 5.2 Page 11 recording of agreements regarding any limitations placed on residents as a result of risk assessments conducted by the home. It is required, however, that the monthly review of risk assessments be recorded to evidence that they are reviewed regularly. Recorded evidence confirmed that residents’ health needs are being met through consultation with a variety of health care professionals. The inspector received feedback forms from eight care managers and one health care professional, all of which were very positive about the care and support provided by the home and one of which specified that the home is particularly good at caring for and supporting residents who have challenging behaviour. The receipt, storage and disposal of medicines at the home were found to be appropriate. Medication records within the home were satisfactory, with no gaps in the medical administration record (MAR) sheets. Use of the code ‘F’ on medication administration records was accompanied by an explanation of its meaning in each case to avoid confusion. As required at the previous inspection the administration of medicines in the form of creams or lotions was now being recorded on medication administration records as appropriate. Residents and their relatives confirmed that their privacy and dignity were respected and also spoke very positively about the support and accessibility of the home’s management. Relatives of one resident told the inspector that the care and support provided by staff had been of a high standard, beyond their expectations, particularly when dealing with challenging behaviour. Avon Lodge DS0000062486.V317464.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 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A number of activities are available to residents with support from staff, but more choices should be available to them to ensure that all tastes are catered for. Residents are encouraged to maintain contact with their family members and friends and are given choices about the way in which their care is provided. Residents are satisfied with the quality of food provided at the home, however insufficient recording of alternatives available, makes it unclear if sufficient choices are available to them. EVIDENCE: Avon Lodge DS0000062486.V317464.R01.S.doc Version 5.2 Page 13 A number of activities are available to residents including board games, painting, singing, gentle exercise, entertainers and video afternoons. Staff told the inspector that most recently they had been making Xmas cards, using a purpose bought kit, with those residents who were interested. Visitors spoken to at the time of the inspection confirmed they were encouraged to visit the home. In addition to friends and relatives, and health and social care professionals, a mobile library and a hairdresser visit the home and magazines and newspapers can also be ordered by residents at the home. One resident attends a local church regularly and attempts have been made to forge links with local churches for residents who are interested in attending religious services. Another resident goes out independently following an appropriate risk assessment by the home. However insufficient evidence was available in residents’ daily records or through observation of activities at the home, that the residents who choose or are unable to join in the group activities, receive sufficient stimulation in the home. This is required. The inspector was concerned that the inclusion of residents’ laundry among staff duties, may detract from the time staff have to spend with residents in carrying out activities of their choice. A recommendation is made accordingly. Residents and relatives spoken to said that staff members offer residents choices about their care and activities to be undertaken at the home. The manager advised that staff occasionally take residents out on trips to the local shops, however there was insufficient recording to evidence this. It is required that more activities be available to residents especially outside of the home. Residents advised that there had been an improvement in the quality of food served at the home and several spoke enthusiastically about the meals provided. Discussions with residents indicated that, although they were able to choose alternatives if they did not like the main meal, this was rarely done. As appropriate, additional kitchen staff had been employed by the home including a full time chef, to meet the needs of a full occupancy of residents. As required there was better recording of the food served to residents in the home, and storage temperatures of refrigerated and frozen foods. However there was insufficient recording of alternatives available to residents including cultural alternatives (although one resident advised that they did receive West Indian food regularly). Menus also did not always make clear which fruit and vegetables were included in meals, in order to determine whether a balanced and nutritious diet is available to residents. A requirement is made accordingly. It remains recommended that pictorial formats be produced to illustrate the home menus for residents and assist them in making choices for each meal. Avon Lodge DS0000062486.V317464.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 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be sure that their concerns about the home will be addressed appropriately. An adult protection policy is available for the home, and the majority of staff have undertaken training in this area to ensure that the risk of residents being abused, is minimised. EVIDENCE: The home’s complaints procedure is appropriate to protect the interests of residents. Feedback from residents and relatives indicated that they felt able to express concerns about the home, and that the management were very receptive to their opinions. The complaint record was maintained up to date including actions taken to address each concern or complaint. The home has an appropriate procedure regarding the protection of vulnerable adults, and since the previous inspection a further fourteen staff members had undertaken training in this area. As required under Standard 35, improved procedures had been put in place to ensure appropriate recording of monies and valuables stored on behalf of residents. Avon Lodge DS0000062486.V317464.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a pleasant environment that is well furnished, clean and hygienic and purpose built to meet their needs. They have access to a range of comfortable communal areas both inside and outside of the home. Requirements are made regarding the need for further vigilance to ensure that there are no unpleasant odours in residents’ rooms and a schedule for redecoration to ensure that a high standard of decoration is maintained. EVIDENCE: Avon Lodge DS0000062486.V317464.R01.S.doc Version 5.2 Page 16 The home was recently decorated and furnished, giving it a bright and inviting appearance. Feedback from residents and relatives indicated that a high standard of housekeeping is provided at the home. Bedrooms and communal areas are comfortable and well furnished. The home has adequate communal areas and a sufficient number of toilets and bathrooms. As required, new arrangements had been put in place for storage of the clinical waste both inside and outside of the home, so that it does not pose an infection control or fire risk to residents. The minor repairs required at the previous inspection had also been addressed as appropriate. Residents and relatives spoken to advised that the standard of cleanliness in the home was high, and this was indeed the case at the time of the inspection, with the exception of approximately three bedrooms, in which there was an unpleasant odour, and a number of light fittings in the corridors that needed to be cleaned from insect debris. The manager advised that housekeeping staff clean a number of carpets in the home each day, and that this is usually very effective. Whilst the difficulty of totally eradicating offensive odours in a home of this nature is appreciated, a requirement is made regarding the need for further vigilance in cleaning carpets in residents’ rooms. The inspector noted that there had been a number of problems arising from the laundering of residents’ clothes in the months prior to the inspection, and that the manager had taken action to address this problem. There appeared to have been an improvement in this area more recently, however it is recommended that the deployment of care staff to undertake laundry duties be reviewed. It is recommended that a further COSHH cupboard (for hazardous chemicals) be provided on the first floor of the home for use by care and domestic staff. It is also recommended that larger and better-equipped staff room facilities be provided for staff members, as the current staff room is too small to meet the needs of the staff members on duty. Finally it was noted that although bedrooms had been recently decorated, the paintwork in a number of rooms was being worn away in patches from contact with furniture. It is required that a schedule for redecoration be produced to address this. Avon Lodge DS0000062486.V317464.R01.S.doc Version 5.2 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 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 good. This judgement has been made using available evidence including a visit to this service. The home operates safe recruitment practices, and there are sufficient staff scheduled to work in the home to meet residents’ needs. Residents and relatives are confident about the ability of staff to meet residents’ needs effectively. Management are aware of staff training needs and progress has been made in meeting these with plans in place to ensure that remaining needs are addressed. Further staff need to undertake training in dementia, fire safety, first aid and challenging behaviour to ensure the protection of residents. EVIDENCE: Avon Lodge DS0000062486.V317464.R01.S.doc Version 5.2 Page 18 Five staff files were inspected and these were found to contain application forms, two references, proof of identity documents and the other records specified under Schedule 4(6) of the Care Homes Regulations 2001. Satisfactory Criminal Record Bureau (CRB) disclosures were available for these staff members as appropriate. Training certificates were available for training completed by staff members and the manager indicated that approximately 50 of care staff were trained to at least NVQ level two in care or equivalent. Staff spoken to were knowledgeable about their role and responsibilities within the home. At the previous inspection the manager advised that fourteen staff members had undertaken training in dementia, first aid, health and safety, manual handling and medication for older people. Since then further staff had undertaken training in adult protection, infection control, manual handling, constipation and food hygiene. The manager advised that he had booked ten staff on to computer training, three staff on continence training and one staff member on tissue viability training in the new year. It remains required that all staff undertake training in fire safety. The manager advised that this was due to be undertaken shortly. It is also required that further staff undertake training in first aid and managing challenging behaviour. It is recommended that staff undertake training in care planning, as the manager himself is currently primarily responsible for updating care plans. It is recommended that the staff application form should be updated to include a statement by prospective staff members as to why they are suitable for the position, and that further guidance regarding restraint be available to staff members. Induction records were available for some but not all staff and there were insufficient supervision records to meet the standard of at least six times annually. This is due in part to the manager not having a deputy for a significant part of the year. A requirement is made accordingly under Standard 36. Following discussion with staff, residents and relatives it is recommended that the number of staff working in the home on the early shift be reviewed to ensure sufficient cover for laundry duties and activities. Relatives spoken to praised the professional manner in which staff work within the home and their communication skills with both residents and visitors to the home. Avon Lodge DS0000062486.V317464.R01.S.doc Version 5.2 Page 19 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, 32, 33, 35, 36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home manager is appropriately qualified and experienced and remains commended regarding the relationship that he has built up with residents and relatives and his leadership of the home in the best interests of residents. Frequent monitoring visits are carried out by the registered provider ensuring that the home is run to a high standard. However more frequent staff supervision and staff meetings are needed to ensure that the home is run in the best interest of residents. Improvements had been made in the recording of residents’ finances kept for safekeeping by the home to ensure their protection from financial abuse. There is a high standard of practice in health and safety at the home to protect the safety of residents. Avon Lodge DS0000062486.V317464.R01.S.doc Version 5.2 Page 20 EVIDENCE: The manager for the home has been successfully registered with the CSCI and has over thirteen years of experience working with older people including those diagnosed with dementia and has been the registered manager of another care home belonging to the provider for over three years. He has obtained the Registered Managers Award at NVQ level 4 and is an active member of the Alzheimer’s’ Society. Feedback forms received regarding the home in addition to discussions with residents and relatives at the home indicated that there are clear communication channels at the home. They also unanimously praised the manager’s leadership of the home, the support that he provides to relatives and his availability to meet with residents and relatives about any issues of concern within the home throughout the day. The manager is commended for his performance in this area. The manager advised that he has also received significant support from the area manager for the home. The majority of residents manage their own finances with support from their family or solicitors. Where the home is asked to keep residents’ funds for safekeeping, records are maintained. Inspection of the records for three residents indicated that these records were now being maintained accurately, matching the actual monies stored for each resident in each case. The inaccuracies noted at the previous inspection were also explained to the satisfaction of the inspector. As required a record was being maintained of all valuables stored on behalf of residents including details of when they are returned. However the records did not specify the location of these items e.g. in the safe, or worn by the resident, or kept in the resident’s own room. A requirement is made accordingly. Since the previous inspection, records indicated that the frequency of staff receiving one-to-one supervision had decreased, so that it did not meet the national minimum standard of at least six times annually. There were also insufficiently frequent staff meetings being held at the home, and a requirement is made accordingly. This is due in part to the manager not having a deputy manager for a large part of the year, but may also be partially due to the manager not delegating sufficient tasks e.g. updating care plans, to staff members, resulting in lack of time to adequately supervise staff. However there had been a great deal of progress in arranging residents meetings at the home. Records were available of the content of these meetings, which were being undertaken in small groups of approximately six residents, and useful feedback had been obtained as appropriate. Avon Lodge DS0000062486.V317464.R01.S.doc Version 5.2 Page 21 Monthly inspections by the area manager for the home are taking place and a quality assurance audit had also been undertaken for the home. Health and safety checks for the home were satisfactory including up to date safety certificates for electrical and gas safety, portable appliances, hoists, legionella, the call system, fire fighting and prevention equipment and regular fire safety checks. Records were also available for the hot water temperature from outlets available to residents, specifying hot water outlets that have been tested on each occasion to ensure that these did not exceed 43°C. As noted under Standard 26, the storage of clinical waste inside and outside of the home, had been improved to ensure that this no longer represents an infection control risk or a fire hazard. Avon Lodge DS0000062486.V317464.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 X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 4 3 X 2 2 X 3 Avon Lodge DS0000062486.V317464.R01.S.doc Version 5.2 Page 23 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 OP7 Regulation 13(4a) 14(2a) Requirement Timescale for action 02/02/07 2. OP12 3. OP15 4. OP19 5. OP26 The registered persons must ensure that risk assessments for individual service users are reviewed at least monthly. 16(mn) The registered persons must ensure that service users who do not join in group-activities receive sufficient stimulation and that this is recorded. 17(2) The registered persons must Schd4(13) ensure that the record of food served at the home includes alternatives provided to individual service users including cultural alternatives and specifies fruit and vegetables included. 23(2d) The registered persons must provide a schedule for the redecoration of service users’ rooms, where paintwork on the walls is worn away by furniture, to the local CSCI area office. 23(2d) The registered persons must ensure that adequate carpet cleaning is undertaken throughout the home to ensure that there are no unpleasant odours, that the light filters in the corridors are cleaned. DS0000062486.V317464.R01.S.doc 02/02/07 19/01/07 02/02/07 22/12/06 Avon Lodge Version 5.2 Page 24 6. OP29 OP32 18(1ci)(2) 7. OP30 18(1ci) 8. OP35 17(2) Schd 4(9) The registered persons must 16/02/07 ensure that up to date induction records are available for all new staff and arrange more frequent supervision sessions with staff and staff meetings. The registered persons must 30/03/07 ensure that all staff are provided with training in first aid, challenging behaviour, fire safety and care planning, and that more staff receive training in working with people who have dementia (Previous timescales of 31/03/06 and 29/9/06 partially met). The registered persons must 05/01/07 ensure that the record of all valuables stored on behalf of service users includes the location where they are stored. 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 OP1 Good Practice Recommendations It remains recommended that an alternative format be considered for the service users guide that may be more accessible to service users who are diagnosed with dementia. It remains recommended that pictorial formats be produced to illustrate the home menus for service users and assist them in making choices for each meal. It is recommended that a further COSHH cupboard (for hazardous chemicals) be provided on the first floor of the home. It is recommended that larger and better-equipped staff room facilities be provided for staff members. It is recommended that the number of staff working in the home on the early shift be reviewed to ensure sufficient cover for laundry duties and that more varied activities are DS0000062486.V317464.R01.S.doc Version 5.2 Page 25 2. 3. 4. 5. OP15 OP19 OP19 OP27 Avon Lodge 6. OP36 available to service users, both inside and outside of the home. It is recommended that the staff application form should be updated to include a statement by prospective staff members as to why they are suitable for the position, and that further guidance regarding restraint be available to staff members. Avon Lodge DS0000062486.V317464.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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 Lodge DS0000062486.V317464.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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!