CARE HOMES FOR OLDER PEOPLE
Avon Lodge 33 Bridgend Road Enfield Middlesex EN1 4PD Lead Inspector
Susan Shamash Key Unannounced Inspection 30th May 2006 11:15 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.V291415.R01.S.doc Version 5.1 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.V291415.R01.S.doc Version 5.1 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.V291415.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 19th December 2005 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 May 2006, weekly fees range from £495 to £550. Current CSCI inspection reports are available for residents and relatives to see from the manager’s office at the home. Avon Lodge DS0000062486.V291415.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection visit lasted approximately eight 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. This was the second inspection of the home since it became operational following refurbishment. The inspector spoke to approximately ten residents, four relatives and eight staff members (including four night staff workers). The inspector also had the opportunity to join residents for a meal at the home. 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 has recently been decorated and refurbished 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. The manager is commended for his ongoing involvement in fostering good relationships between staff, residents and relatives. 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. Avon Lodge DS0000062486.V291415.R01.S.doc Version 5.1 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. What has improved since the last inspection? What they could do better:
In view of the newness of the home, the inspector remains impressed with the systems that have been set up to ensure the protection of residents. It remains recommended that pictorial formats be produced for the service users guide and menus at the home. Each administration of medicines in the form of creams or lotions must be recorded on the medication administration records. It is recommended that more activities be available to residents outside of the home and that key staff undertake training in activities for adults with dementia. Avon Lodge DS0000062486.V291415.R01.S.doc Version 5.1 Page 7 Repairs must be undertaken to the windowpane in the identified ground floor toilet room, and the mirror in room 15, and the walls in room 13 require repainting. The manager advised that these issues had been addressed shortly after the inspection. Up to date records must be maintained of food served to residents in the home and storage temperatures of refrigerated and frozen foods. Further training must be arranged to ensure that all staff members are trained in dementia, adult protection, infection control and fire safety. All kitchen staff and any staff involved in serving, handling and assisting residents with food must undertake training in food hygiene. Regular staff meetings and resident meetings must be held at the home and a summary of the findings of the annual quality assurance audit for the home must be sent to the CSCI. It remains required that regular checks must be undertaken to ensure that accurate records are maintained of residents’ monies stored in the home for safekeeping. A record must also be maintained of all valuables stored on behalf of residents including details of when they are returned to residents. Clinical waste must be stored securely in the home away from clean laundry to prevent cross infection. Clinical waste must also be stored securely outside of the home within a locked facility and must not obstruct any of the home’s fire escape routes. It is recommended that the closure of self-closing doors during weekly fire alarm tests be recorded and that an extra set of keys, accessible via a breakglass facility be available in the home in the event of an emergency. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Avon Lodge DS0000062486.V291415.R01.S.doc Version 5.1 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.V291415.R01.S.doc Version 5.1 Page 9 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3. (Standard 6 is not applicable) Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the 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. Residents are protected by appropriate contracts of terms and conditions with the home. EVIDENCE: Avon Lodge DS0000062486.V291415.R01.S.doc Version 5.1 Page 10 A detailed statement of purpose and service users guide were available for the home as appropriate. 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 service user 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. Files also contained signed statements of terms and conditions between residents (or their advocates) and the home as appropriate. Residents and relatives spoken to indicated that there had been opportunities to visit the home prior to admission. Avon Lodge DS0000062486.V291415.R01.S.doc Version 5.1 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 at least once during a 12 month period. 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 from evidence gathered both during and before the visit to this service. Residents’ health, personal and social care needs have been assessed and care plans are in place for each resident as appropriate. These included recorded evidence of resident/advocate consultation and greater detail recorded in review notes, as required at the previous inspection. Administration of medicines is generally recorded appropriately, however the administration of medicines in the form of creams of lotions must also be recorded to ensure 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: Five 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. As required at the previous inspection this consultation was now being recorded on care plans as appropriate in the form of residents’ or their
Avon Lodge DS0000062486.V291415.R01.S.doc Version 5.1 Page 12 relatives/advocates’ signatures. Residents and relatives spoken to confirmed that they were consulted regarding their preferences. As required at the previous inspection, there was also greater detail included within monthly reviews of care plans and recording of agreements regarding any limitations placed on residents as a result of risk assessments conducted by the home. As recommended, staff at the home record their own notes of review meetings taking place with social workers, so that actions can be put in place without needing to wait for the official minutes to be received. Recorded evidence confirmed that service user’s health needs are being met through consultation with a variety of health care professionals. On the day of the inspection the opticians, district nurse and GP for the home visited. The inspector had the opportunity to speak to the district nurse and GP, and they confirmed that staff at the home are knowledgeable regarding the health needs of residents and provide them with the necessary information to undertake their roles. The receipt, storage and disposal of medicines at the home were found to be appropriate. Medication records within the home were generally satisfactory, with no gaps in the medical administration record (MAR) sheets as required. As required, use of the code ‘F’ on medication administration records was accompanied by an explanation of its meaning in each case to avoid confusion. However it was noted that the administration of medicines in the form of creams or lotions was not always recorded on medication administration records, and a requirement is made accordingly to ensure that residents’ medication needs are fully met. 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. Avon Lodge DS0000062486.V291415.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. There had been an improvement in the number of activities available to residents with support from staff at the home, so that they receive sufficient stimulation. 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, and an improvement was noted in the number of choices available to them and flexibility of kitchen services. However records of food served must be kept up to date to evidence that residents’ nutritional needs are being met. EVIDENCE: Avon Lodge DS0000062486.V291415.R01.S.doc Version 5.1 Page 14 A number of activities are available to residents including board games an exercise group, reminiscence group and occasional trips out to local shops. The manager advised that organised outings were also planned for residents. At the previous inspection a significant number of residents spoken to indicated that there were not always sufficient activities provided for them and that they were frequently bored. It was therefore required that further provision be made with regard to activities for residents at the home. 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. Residents and relatives spoken to said that staff offer residents choices about their care and activities to be undertaken at the home. Choices of activities include trips out shopping with staff members, films, bingo, reminiscence, painting, music, skittles, entertainers and gardening. The manager advised that he was intending to arrange for some daytrips out to a stately home or the coast, for residents over the summer. It is recommended that more activities be available to residents outside of the home and that key staff undertake training in activities for adults with dementia. The inspector had the opportunity to eat a meal with residents in the dining area and noticed an improvement in the quality of food served. Discussions with residents indicated that, although they were able to choose alternatives if they did not like the main meal provided, this was rarely done. However 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. As required at the previous inspection additional kitchen staff had been employed by the home including a full time chef, to meet the needs of a speedily growing number of residents. However there were gaps in the records of food served to residents in the home, and storage temperatures of refrigerated and frozen foods, and 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.V291415.R01.S.doc Version 5.1 Page 15 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the 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, but there is a need for further staff training in this area and for improved procedures for safeguarding residents’ finances, to ensure that the risk of residents being abused is minimised. EVIDENCE: Avon Lodge DS0000062486.V291415.R01.S.doc Version 5.1 Page 16 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 further staff members had undertaken training in this area. However it remains required that all staff members undertake adult protection training to ensure the protection of residents. The manager advised that further training in adult protection would be provided to staff on 20/6/06. As described under Standard 35, improved procedures are required to ensure that records of monies and valuable stored for residents are accurate. Avon Lodge DS0000062486.V291415.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the 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. The management are commended for bringing about a wide range of changes to provide a safe and comfortable environment for residents. Requirements are made regarding the need for a small number of minor repairs to ensure the comfort of residents, and the storage of clinical waste both inside and outside of the home to protect the health and safety of residents. Avon Lodge DS0000062486.V291415.R01.S.doc Version 5.1 Page 18 EVIDENCE: 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 at the previous inspection the shower had been fitted on the ground floor. The manager advised that an additional bath hoist was due to be obtained for the home. On inspection of the building the inspector noted a small number of minor matters requiring repair including a broken windowpane in a ground floor toilet room, a cracked mirror in room 15 and the walls in room 13 requiring repainting. The manager advised that these issues were dealt with shortly after the inspection. The inspector was concerned to note, however, that the clinical waste was being stored in the laundry room, and in toilet rooms to which residents had access. Clinical waste was also found to be stored in plastic bags to the rear of the home, obstructing one of the home’s fire escape routes presenting an infection control risk and a fire hazard. A requirement is made accordingly. Avon Lodge DS0000062486.V291415.R01.S.doc Version 5.1 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 at least once during a 12 month period. 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 from evidence gathered both during and before the 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. 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, adult protection, infection control, fire safety and food hygiene to ensure the protection of residents. EVIDENCE: Satisfactory Criminal Record Bureau (CRB) disclosures were available for staff members working in the home as appropriate. 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. 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. The manager advised that fourteen staff members had undertaken training in dementia, first aid, health and safety, manual handling and medication for
Avon Lodge DS0000062486.V291415.R01.S.doc Version 5.1 Page 20 older people. Further training in care planning and tissue viability is planned for senior staff. Although there has been significant progress in this area it remains required that all staff undertake training in dementia, adult protection, infection control and fire safety. All kitchen staff and any staff involved in serving, handling and assisting residents with food must undertake training in food hygiene. Clearly the number of staff working in the home will continuously need to be reviewed as further residents are admitted to the home. Avon Lodge DS0000062486.V291415.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The home manager is appropriately qualified and experienced and is commended regarding the relationship that he has built up with residents and relatives. There are clear communication mechanisms within the home providing protection for residents in having their needs met effectively and consistently. Frequent monitoring visits are carried out by the registered provider ensuring that the home is run to a high standard. However regular staff meetings and residents/relatives meetings are needed to ensure that the home is run in the best interest of residents. Staff receive regular supervision ensuring that residents are provided with appropriate support. However there remains room for improvement in the recording of residents’ finances kept for safekeeping by the home to ensure their protection from financial abuse.
Avon Lodge DS0000062486.V291415.R01.S.doc Version 5.1 Page 22 There is generally a high standard of practice in health and safety at the home but procedures for the storage of clinical waste must be reviewed to fully protect residents. 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. Discussions with staff, residents and relatives visiting the home indicated that there are clear communication channels at the home. The manager advised that he has also received significant support from the area manager for the home. As required at the previous inspection, records indicated that staff receive oneto-one supervision at least six times annually and these sessions are recorded. The manager advised that it had not yet been possible to arrange regular staff and resident meetings at the home. A requirement is made accordingly. Monthly inspections by the area manager for the home are taking place and the manager is aware that a quality assurance audit will need to be undertaken at least annually. A summary of the findings of this audit must be sent to the local CSCI area office. 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. However inspection of the records for four residents indicated that these records are still not always accurately matching the actual monies stored for each resident. It remains required that regular checks be put in place to ensure that records of monies stored for residents are accurate, and that any inaccuracies are explained. A record must also be maintained of all valuables stored on behalf of residents including details of when they are returned for residents. Health and safety checks for the home were generally 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. As required at the previous inspection regular recording was being undertaken of the hot water temperatures specifying hot water outlets that have been
Avon Lodge DS0000062486.V291415.R01.S.doc Version 5.1 Page 23 tested on each occasion to ensure that these do not exceed 43°C. The manager advised that the ‘dorguard’ devices had been upgraded to self-closing doors connected to the fire alarm system. These were being monitored weekly during alarm call point tests. As noted under Standard 26, the inspector was concerned to note that clinical waste was being stored in the laundry room, and in toilet rooms to which residents had access. Clinical waste was also found to be stored in plastic bags to the rear of the home, obstructing one of the home’s fire escape routes presenting an infection control risk and a fire hazard. A requirement is made accordingly. The inspector was concerned to note that only one set of keys were available at the home to open the front door in the event of fire. The manager arranged for a spare set to be made available during the inspection and advised that an extra set would be provided behind a break-glass box in the event of an emergency. Avon Lodge DS0000062486.V291415.R01.S.doc Version 5.1 Page 24 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 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 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 X 2 X 2 3 X 2 Avon Lodge DS0000062486.V291415.R01.S.doc Version 5.1 Page 25 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(2) Requirement Timescale for action 30/07/06 2. OP15 13(4) 17(2)(13) 3. OP19 23(2bd) 4. OP30 18(1ci) The registered persons must ensure that each administration of medicine to service users in the form of creams or lotions is recorded on medication administration records. The registered persons must 07/07/06 ensure that records of food served to residents in the home and storage temperatures of refrigerated and frozen foods are maintained up to date. The registered persons must 28/07/06 ensure that the windowpane in the identified ground floor toilet room and the mirror in room 15 are repaired, and the walls in room 13 are repainted. The registered persons must 29/09/06 ensure that all staff members undertake training in dementia, adult protection, infection control and fire safety (Previous timescale of 31/03/06 partially met). All kitchen staff and any staff involved in serving and handling food or assisting residents with food must undertake training in food
DS0000062486.V291415.R01.S.doc Version 5.1 Avon Lodge Page 26 5. OP35 17(2) Schd 4(9) hygiene. The registered persons must ensure that regular checks are put in place to ensure that records of monies stored for service users are accurate, and that any inaccuracies are explained. (Previous timescale of 20/01/06 not met). A record must also be maintained of all valuables stored on behalf of service users including details of when they are returned for service users. The registered persons must ensure that regular staff meetings and resident meetings are held at the home and that the minutes of these meetings are available for inspection. 30/06/06 6. OP35 24 29/09/06 7. OP38 13(4) 23(4b5) A summary of the findings of the annual quality assurance audit for the home must be sent to the local CSCI area office. The registered persons must 07/07/06 ensure that clinical waste is stored securely in the home away from clean laundry. Clinical waste must also be stored securely outside of the home and must not obstruct any of the home’s fire escape routes (with immediate effect). Avon Lodge DS0000062486.V291415.R01.S.doc Version 5.1 Page 27 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 is 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 is recommended that more activities be available to residents outside of the home and that key staff undertake training in activities for adults with dementia. It is 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 the closure of self-closing doors be recorded during weekly fire alarm tests, and that an extra set of keys for the home be made available in the home, accessible via break-glass, in the event of an emergency. 2. 3. 4. OP14 OP15 OP38 Avon Lodge DS0000062486.V291415.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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