Inspection on 16/05/05 for Avondale

This inspection was carried out on 16th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

Avondale 12/09/06

Avondale 22/09/05

Avondale 06/09/04

Avondale 15/04/04

Avondale 15/01/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Avondale 62 Stratford Road Salisbury Wiltshire SP1 3JN Lead Inspector Roy Gregory Unannounced 16th May 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Avondale D51_D01_S15889_AVONDALE_V193921_160505_Stage4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Avondale Address 62 Stratford Road Salisbury Wiltshire SP1 3JN 01722 331312 01722 416041 roger.mouncher@turning_point.org uk Turning Point Limited Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Application pending for registration of Roger Mouncher Care Home 14 Category(ies) of LD Learning Disability registration, with number of places Avondale D51_D01_S15889_AVONDALE_V193921_160505_Stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1 The total number of service users to be accomodated at any time must not exceed 14. 2 Two beds are to be used for respite only. 3 Staffing for the two respite beds is to be arranged separately to the main staffing for the home and is dependent upon the assessed needs of individuals receiving this service. Staffing for service users receiving respite care is therefore additional to the staffing levels below. 4 The home must comply with the Residential Forum Guidance on staffing levels for care homes for 12 service users with high needs. Staffing levels must reflect the numbers and needs of service users in the home at any one time. A minimum of 5 staff must be on duty in the home when all service users are present. 5 Due to the complex needs of the service users cared for in the home there must at all times be a member of staff who has received appropriate training in the following: PEG feeds, suctioning, administration of rectal stesolid, medication administration and safe use of oxygen. Date of last inspection 6th September 2004 Brief Description of the Service: The home dates from the 1980s. It was originally a health service establishment. It is now operated by Turning Point, a voluntary organisation that also provides other care services for this client group within the city of Salisbury. Bomford and Corinthian Housing Association currently own the property, but there are ongoing negotiations to transfer the property to another registered social landlord. The home has two floors connected by passenger lift and provides single room accommodation to 12 service users. There is direct access from the downstairs sitting room to the large garden, which is mainly to lawn or patio. Also downstairs are the dining room and kitchen. The latter is not suited to access by service users. Specialist bathroom facilities and other aids are provided. Additional to the permanent resident group, there are two bedrooms for respite use, staffed separately from the home as a whole; this provision is scheduled to cease in the near future, when another local provider becomes available. Adjacent to the home is a day centre operated by Turning Point, which is extensively used as a resource by home residents. Avondale is situated in an attractive residential area a short drive both from Salisbury city centre, where there are good public transport connections, and from open countryside. There is car parking on site. Avondale D51_D01_S15889_AVONDALE_V193921_160505_Stage4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place between 9:15 a.m. and 6:30 p.m. on Monday 16th May 2005. The inspector, Roy Gregory, met with seven residents and talked with four members of staff. Additionally one of the project workers (deputy managers) was available throughout the morning, and the recently appointed manager Roger Mouncher through the afternoon, later joined by Martin Clarke, of Turning Point, who had been managing the service for some time. The inspector selected a number of care plans to compare observations of care and staff comments with written records. Other records consulted included those relevant to recruitment, staffing, and protocols with external health professionals. All communal areas of the building were visited and four individual rooms were seen. The inspector had the benefit of speaking with three visitors during the day, all relatives of service users. There was also a visit during the day to the Focus Point day activity centre next door to the home, which some residents were attending at the time. The pharmacist inspector Mary Collier attended at the home in the morning to review storage and administration procedures for medications. Her findings are reflected in this report. This was the first inspection of the home since its re-registration as a care home (in place of its former nursing home status), a process that has occupied much scrutiny by the Commission. Following the previous inspection in August and September 2004, at which a number of requirements were set, there were monitoring visits made by inspectors in November 2004 and January 2005. The Commission has received concerns about aspects of care in telephone calls from some relatives of residents. What the service does well: What has improved since the last inspection? As part of the transition to care home without nursing, Avondale has been required to recruit sufficient care staff to end the home’s previous reliance upon agency nursing staff, with its associated lack of continuity of care for residents. This process has been carried out thoroughly, producing a motivated Avondale D51_D01_S15889_AVONDALE_V193921_160505_Stage4.doc Version 1.30 Page 6 staff group available to provide at least five care staff on each shift. Healthcare protocols have been established with community health professionals. In contrast to previous inspections, the pharmacist inspector has made no requirements in respect of medication use on this occasion. Improvements to the décor of the home have been made since the previous inspection, and two new Parker baths have been provided. Standards of cleanliness have been much improved. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Avondale D51_D01_S15889_AVONDALE_V193921_160505_Stage4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Avondale D51_D01_S15889_AVONDALE_V193921_160505_Stage4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) (see below) None of these Standards was considered within this inspection. There have been no admissions of new service users, and none are in prospect. EVIDENCE: Avondale D51_D01_S15889_AVONDALE_V193921_160505_Stage4.doc Version 1.30 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7 & 9 Individual plans direct care. There is evidence of review, but not at a frequency or depth that reflects significant change, or involvement by service users or their supporters. On an individual level there is appropriate support to making decisions. Risk assessments in place are not fully aligned to knowledge or practice in the home, and a lack of coherent format leads to a risk that assessments may not be readily understood. EVIDENCE: There were support plans in place for all service users, each using a common format. These presented as comprehensive, and gave clear guidance on how care should be offered from a service user perspective, for example in morning and bedtime routines. Newly appointed staff said they had been given time to familiarise themselves with care plans, alongside “shadowing” staff who were familiar with delivering care. A relative of a resident has expressed the concern that support plans can become out of date through not being up-dated with agreed changes. There was evidence of six-monthly planned review of plans, but not of interim reviews in response to changes of need or practice. Neither was it readily ascertainable whether the planned reviews had resulted in changes to plans; a review tracking sheet would be a useful addition. Meanwhile, progress has been continuing on “person–centred planning” for all service users, involving family members with carers. This process is Avondale D51_D01_S15889_AVONDALE_V193921_160505_Stage4.doc Version 1.30 Page 10 spearheaded by external Turning Point personnel; copious records showed it to be generating information and ideas. In one case, a resident’s interest in playing electronic keyboard had been discovered, leading to purchase of an instrument and encouragement to play it. A greater link between the personcentred planning and support plans would allow the latter to become more dynamic, with a greater emphasis on resident self-determination and goal setting. It may be that some family members would like to counter-sign support plans and to be involved directly in the review process. Service users demonstrated a range of decision-making during the day. At lunchtime, one resident had decided against remaining all day in the day centre next door, and instead returned to the home for lunch and some quiet time before deciding to return. Others exercised choice over which rooms in the home to use at any time. One spoke of having stayed up very late the previous night, and said he always chose rising and retiring times. Staff exhibited good communication skills in striving to understand and facilitate residents’ choices. There was a discussion between a member of staff and a relative about a resident’s visual and perceptive abilities. Support plans were informed by a variety of individual risk assessments. Although there was some evidence of review of these, such review may be cursory, as some examples given to the inspector of measures to control particular risks were not reflected in the risk assessments for the individuals concerned. It was also noted that three different formats for risk assessments were in use, which needed to be rationalised. The manager informed that the provider was imminently bringing in a new risk assessment format, the introduction of which would provide impetus to the necessity to bring all assessments up to date and into line. Avondale D51_D01_S15889_AVONDALE_V193921_160505_Stage4.doc Version 1.30 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 12, 13, 14 & 17 Service users are offered a range of organised and spontaneous activities, including support to access community resources, for the purposes of meeting leisure and development needs. Mealtimes allow for private or social enjoyment of meals, which in turn allow for individual tastes and needs. EVIDENCE: The person centred planning initiative is helping to bring residents’ interests and potential for development to the fore. The provider’s vision for the future is to aim to prepare residents for living in smaller units. This means there is an emphasis now on encouraging more interaction with the community. A number of residents went out in the home’s minibus on the day of inspection, one went shopping with one-to-one support and others attended all or part of the day at Focus Point day centre next door. There was evidence of other day resources used as part of individuals’ activity plans, such as the local college. Staff and management spoke of intentions to use Focus Point facilities during evenings, e.g. the training kitchen. Residents benefit from contact with outreach workers from outside the home. Avondale D51_D01_S15889_AVONDALE_V193921_160505_Stage4.doc Version 1.30 Page 12 Cooked meals were served at lunch and teatime. Staff gave sensitive support and assistance where needed. The dining room offered a pleasant environment and meals were well presented. Staff took their meals alongside service users and included them in conversations. During the lunchtime there was discussion about a possible theatre trip. Care plans commented on nutritional needs and degrees of assistance necessary, and staff were familiar with this guidance. The menu was planned for the week. Residents appeared to enjoy their meals. Avondale D51_D01_S15889_AVONDALE_V193921_160505_Stage4.doc Version 1.30 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19 & 20 Staff offer personal support that matches service users’ needs and recorded preferences. Healthcare needs are clearly recorded and their management includes use of external consultation and guidance in order to identify and meet needs. Medication practice is competent and protects service users’ interests. EVIDENCE: Care plans were detailed in describing individual support necessary in terms of ascertained resident likes and dislikes. There was good guidance about communication needs, for example with regard to facial expression, and also about emotional aspects of the receipt of care. Observations of care interactions fitted with staff members’ confirmation of familiarity with the care plans. It was noted as good practice that for a service user at risk of hospital admissions, there was printed guidance available specifically for the use of hospital staff, and including detailed information about their major medical condition. With the recent change in status from nursing home to residential home without nursing care provided, it has been necessary for the home to agree protocols with outside health professionals in respect of meeting some quite complex care needs. There were, for example, general and individual protocols about pressure area care, and PEG feeding, together with emergency contact numbers. Staff considered that at this stage, they were receiving good back up from the community nursing service. One resident received a nurse visit on the Avondale D51_D01_S15889_AVONDALE_V193921_160505_Stage4.doc Version 1.30 Page 14 day of inspection. Care records showed tracking of appointments for medical services, including dental and optical visits, with outcomes. There was correspondence on individual records from specialists, outpatient clinics and professionals such as occupational therapists. There was evidence of use of fluid charts, and regular weighing. The pharmacist inspector reviewed medication use and associated records, and observed a drug round. The medicines were stored securely and all appropriate records were maintained. Records were seen of service users’ refusals to take medicines, and of medicines that were taken out of the home. Staff had received training in medication handling and other specific health-related tasks that they undertake for service users. Procedures were available for all tasks, and staff appeared to be well informed about medicine use in the home. Written additions to the printed medication administration record were not all signed, dated and checked by two members of staff. Avondale D51_D01_S15889_AVONDALE_V193921_160505_Stage4.doc Version 1.30 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 23 Vulnerable adults procedures are in place, compliant with local inter-agency procedures and readily available to staff. Systems are in use to promote security of residents. EVIDENCE: Avondale staff have demonstrated previously that they are aware of the local vulnerable adults procedures and these have been used appropriately. The guidance was prominent in the area used by staff for routine recording. There have been no issues referred via this procedure since the previous inspection. Access to and from the home is controlled by a coded lock, and baffle handles; whilst the latter have been criticised in the past, their necessity had been recently re-established. Some residents routinely wear light gloves to limit potential for self-harm. This limitation was explained and recorded in respective support plans. Other elements in individual plans reduce risks of neglect or self-harm. Staff were familiar with the contents of support plans and risk assessments. Avondale D51_D01_S15889_AVONDALE_V193921_160505_Stage4.doc Version 1.30 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 27, 28 &30 The environment works for service users in offering space for ease of mobility and choice between sociability or more private space. Individual rooms are well proportioned and lend themselves to being made personal and private. Toilets and bathrooms cater for individual needs in privacy. The home is kept clean and hygienic but for risks posed by rusting radiator covers in bathrooms. EVIDENCE: The layout of the home, including broad corridors and large communal rooms, militates against a “homely” feel, but recent redecoration of these areas, and provision of comfortable furniture, have been effective in making the environment appear bright and cared for. The amount of space provided is valuable to aid residents’ movements around the home, and staff awareness of these. Individual bedrooms were light and well proportioned and reflected the interests and preferences of their occupants; one seen had very recently been repainted, the resident confirming the colour choice as his own. The garden has potential for development as a shared space. It is apparently little used at present, but there was mention of plans for outdoor furniture and raised beds. Provision of shade will be essential. Avondale D51_D01_S15889_AVONDALE_V193921_160505_Stage4.doc Version 1.30 Page 17 The respite area has sitting and dining facilities of its own. It was said that this part of the home might be used in future to offer more private sitting space for upstairs residents, or to provide opportunities for smaller group living. Toilets and bathrooms presented well. One bathroom was being kept locked by day for risk-assessed reasons. Cleanliness throughout the home was of a high order, with no unpleasant odours, and there were many indications of active adherence to infection control procedures. However, rusting radiator covers in some bathrooms and toilets could compromise these measures. The laundry appeared well organised and was clean, including behind the machines. Avondale D51_D01_S15889_AVONDALE_V193921_160505_Stage4.doc Version 1.30 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 34 & 36 Staffing is sufficient in numbers and quality to help ensure service users are safely and consistently supported. Recruitment practices are sound, related to service users’ needs and in line with regulations. Staff do not receive the support they need through regular supervision, neither are new staff inducted in a systematic way that would enable service users and their supporters to have full confidence in the knowledge and value base of those providing their care. EVIDENCE: The home has a history of extensive use of agency staff, with a resultant lack of continuity of staff for residents. It was an essential element in the reregistration as a residential home, that this issue be addressed. As a result there had been a period of recruitment, which included appointment of some staff who had previously worked at Avondale as agency workers. It is a condition of registration that there be a minimum of five support staff on shift; this was being maintained. In fact rotas showed it was often exceeded, because those newly appointed staff who were not yet completely checked in respect of background were unable to assume responsibility for one-to-one personal care and were accordingly shadowing others, including agency workers with existing knowledge of the resident group. This meant that there were plenty of staff to facilitate support care in and out of the home. There remained one support worker vacancy to be filled. In respect of recruitment, required checks were being undertaken and required documentation kept. Avondale D51_D01_S15889_AVONDALE_V193921_160505_Stage4.doc Version 1.30 Page 19 There were detailed records of interviews in all cases. The staff team had a mix of gender, age and experience. However, a systematic induction process was awaited, something that was also remarked on through the Provider’s internal unannounced monitoring visit in April 2005. It was acknowledged that staff individual supervision had not been taking place. The manager and deputies were due to attend training in the provider’s expectations of supervision. Given the home’s change in status and the number of recently recruited staff, this is an area needing priority attention. The manager also expressed an intention to undertake an audit of staff training. Avondale D51_D01_S15889_AVONDALE_V193921_160505_Stage4.doc Version 1.30 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38, 41, 42 & 43 The provider and management team give leadership and direction to the home, resulting in the staff projecting a positive ethos through their approach to care of service users. Record keeping is not fully compliant with regulations, and shortfalls in fire precautions monitoring, especially in relation to drills and staff training, have exposed residents to risk. EVIDENCE: Both inspectors found staff at all levels to be very positive about the shift in direction within the home from nursing, and an emphasis on physical care, to social integration and development of service users’ abilities. Feedback from the relatives of service users suggests they have been more cautious about the change of registration, which is still at a very early stage. In satisfying the Commission of the safety and appropriateness of the re-registration, Turning Point management have had to demonstrate commitment to recruitment of new staff, including appointment of a service manager; to negotiation of health care protocols with health agencies and professionals, with related provision of task-related training to staff; and to consistent provision of sufficient support Avondale D51_D01_S15889_AVONDALE_V193921_160505_Stage4.doc Version 1.30 Page 21 and ancillary staff. This process has in turn demanded that they received backing and resources from the Provider body at a higher level. The newly appointed manager had been in post only a week at the time of inspection. Since then he has been registered as manager. He appeared to have established a rapport with service users and staff. The manager role is supported by three project workers, who have “deputy” status. There were significant gaps in the records of checks on fire precautions, including a shortfall in fire instructions provision to recently appointed staff. It emerged the designated fire precautions person had in fact left without the role being re-designated. Mr Mouncher undertook to rectify this at once, and to include certain of the routine fire checks in a monthly health and safety audit, which he already had planned to start. Consideration to wheelchair maintenance might usefully be a part of this; a staff member reported a wheelchair fault to a service facility for attention to a fault, but was doubtful of receiving a swift response. References to wheelchair repairs were noted in individual plans, but there was no evidence of a systematic approach. Records were kept in good order and fairly easily accessed. Not all staff records contained a recognisable photograph. As required by regulation, the home receives unannounced provider visits that are recorded. These are of good quality, identifying shortfalls and requiring rectification of these. There is also a relatives’ group that meets every two months. Avondale D51_D01_S15889_AVONDALE_V193921_160505_Stage4.doc Version 1.30 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23 ENVIRONMENT Score x 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 x 3 3 x 2 Standard No 11 12 13 14 15 16 17 3 3 3 3 x x 3 Standard No 31 32 33 34 35 36 Score x x 3 3 x 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Avondale Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score x 3 x x 2 2 3 D51_D01_S15889_AVONDALE_V193921_160505_Stage4.doc Version 1.30 Page 23 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 6 Regulation 15 (2)(b,c) 13 (4)(c) Requirement Care plans must be updated to reflect changing needs in addition to routine six-monthly reviews. Risk assessments must be consistent in format and show all means of control of identified risks that are in use. Rusting radiator covers in bathrooms and toilets must be identified and made good. Ensure that all staff receive an annual appraisal; and supervision at least 6 times a year. (Requirement re-stated from previous inspection report). Devise and implement a programme of induction for all newly recruited staff. Records must contain a recent recognisable photograph of each member of staff employed at the home. There must be a designated person responsible for organisation of fire precautions monitoring. All staff must receive routine fire instructions and experience of fire drills. Checks of all fire precautions Timescale for action 16th May 2005 30th June 2005 30th June 2005 Programme to be devised by 30th June 2005 30th June 2005 30th June 2005 16th May 2005 30th June 2005 16th May Page 24 2. 9 3. 4. 30 36 13 (3) 18 (2) 5. 6. 36 41 18 (1)(c) 19 (1)(b) 7. 42 23 (4)(c)(v) 23 (4)(d,e) 23 8. 9. Avondale 42 42 D51_D01_S15889_AVONDALE_V193921_160505_Stage4.doc Version 1.30 (4)(c)(v) 10. 42 23 (2)(c) must be carried out at least at recognised intervals. Health and safety provision must include routine appraisal and servicing of all wheelchairs in use. 2005 30th June 2005 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard 6 20 28 6 Good Practice Recommendations Consider using a tracking sheet in care plans for ready reference of when they have been reviewed and when and in which sections changes have been made. Written additions to the MAR sheets should be checked, signed and dated by two members of staff. The garden should be brought into fuller use as a communal space, with provision made for shade. Invite service users relatives to sign agreement or make other written comment on care plans. Avondale D51_D01_S15889_AVONDALE_V193921_160505_Stage4.doc Version 1.30 Page 25 Commission for Social Care Inspection Avonbridge House Bath Road Chippenham Wiltshire, SN15 2BB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Avondale D51_D01_S15889_AVONDALE_V193921_160505_Stage4.doc Version 1.30 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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!