Inspection on 17/07/08 for Avondale

This inspection was carried out on 17th July 2008.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Avondale 06/08/06

Avondale 01/11/05

Avondale 20/05/05

Avondale 29/03/05

Avondale 13/04/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Avondale 152 New Lane Eccles Manchester M30 7JB Lead Inspector Sue Jennings Unannounced Inspection 09:30 17th and 25th July 2008 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 Avondale DS0000006694.V368038.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. Avondale DS0000006694.V368038.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Avondale Address 152 New Lane Eccles Manchester M30 7JB 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) 0161 707 2303 0161 707 9153 avondale@schealthcare.co.uk Focus Care Centres Ltd Mrs Ayoka Olabisi Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36) of places Avondale DS0000006694.V368038.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. Up to 36 service users requiring nursing or personal care may be accommodated. One named service user who is under 65 years of age and requires personal care may be accommodated. One named service user who is under 65 years of age and requires nursing care may be accommodated Minimum nursing staffing levels as specified in the Notice issued under Section 25(3) of the Registered Homes Act 1984 shall be maintained. Staffing levels as specified in the Residential Forum for Staffing in Care Homes for Older People for service users receiving personal care only shall be maintained. The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 31st May 2008 Date of last inspection Brief Description of the Service: Avondale provides nursing and personal care for up to 36 older people. The detached premises consist of an older house together with a recent extension. The building is set back from a main road close to shops and public transport; there is a car park to the front and gardens and a patio area to the rear. Accommodation is split over two floors and is comprised of 16 single occupancy and ten double occupancy rooms. The main lounge/dining areas are on the ground floor and a smaller lounge is situated on the first floor. There is a passenger lift to the first floor. Avondale DS0000006694.V368038.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. Before the inspection, we also asked the manager of the service to complete a form called an Annual Quality Assurance Assessment (AQAA). This tells us what they felt they did well, and what they needed to do better. The AQAA also helps us to determine if the management views their service in the same way that we do. This visit was undertaken as part of a key inspection, which includes an analysis of any information received by the Commission for Social Care Inspection in relation to this home prior to the site visit. The visit was carried out by two inspectors. It was unannounced and took place over the course of 6 hours on Thursday 17th and Friday 25th July 2008. During the course of the site visits time was spent talking to the manager, 7 residents and 5 members of staff to find out their views of the home. In addition we received completed survey forms from residents and relatives. We spent time examining records and the residents and staff files. A tour of the building was also made. The requirements from the previous inspection had been addressed and there was evidence that the home was continuing to work hard to develop the service. The fees for living at the home range from £354-76 to £474-52 per week. Additional charges were made for hairdressing, trips, newspapers, alcohol, clothing and personal toiletries. What the service does well: People living at the home enjoy the food provided. One person told us “I have never had to ask for something different, I like the meals”. Individuals spoken to told us that staff were friendly and polite”. We saw that staff and residents had a good rapport. Avondale DS0000006694.V368038.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Avondale DS0000006694.V368038.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Avondale DS0000006694.V368038.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are given sufficient information for them to make a decision about moving in and there are systems in place to make sure that people’s needs are assessed before admission. EVIDENCE: A user guide is available which contains information about the service provided. This is available in large print if requested. We saw that there is an admissions procedure and that assessments are completed prior to anybody moving in. Once an individual comes to live there, a care plan is written based on these assessments. These assessments help to Avondale DS0000006694.V368038.R01.S.doc Version 5.2 Page 9 capture the information needed to allow staff to provide personalised care and support. Some people placed by care managers and funded by the local authority had a care manager’s assessment of need on file. We looked at assessments completed for five people and saw that some good information had been recorded. The service does have written contracts in place which should be provided to people and / or their representatives on admission. Avondale DS0000006694.V368038.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 adequate This judgement has been made using available evidence including a visit to this service. Medication practices did not fully protect residents and care plans could be more person centred and better address the health, personal and social care needs of residents. EVIDENCE: Two people who live at the home responded ‘always’ when asked if they received the care and support they needed. One person said ‘usually’. One relative or friend told us “shortness of staff impedes care at times”. We saw five people’s care plans. These gave information about how staff should meet resident’s needs and we saw that this document has been reviewed. The plans could be improved to contain more individual information and to better address social needs. Care plans seen for areas such as personal hygiene included phrases such ‘has weekly bath or shower’. Staff should review these and make sure that specific Avondale DS0000006694.V368038.R01.S.doc Version 5.2 Page 11 person centred information is recorded. For example, does the person like a bath or a shower, which bathroom do they use, what day or time do they prefer and who do they like to help them? The format of care plans did not give the opportunity to be person centred. This means that residents sometimes may not receive care in the way they would choose to. One assessment stated under the heading expressing sexuality “at risk of sexual abuse”. The action required was recorded as “to prevent sexual abuse to promote safety at all times POVA”. This demonstrated little information about why the person is at risk and possibly a lack of understanding of what expressing sexuality really means. This section of the care plan should rather look at how individuals like to present themselves, how they carry out their relationships and what clothes or make up they like to wear in order for them to feel good about themselves. It was of concern that if this individual is at risk of sexual abuse the care plan does not identify how or why the person is at risk or detail the action needed to minimise these risks. There was also no separate risk assessment completed. Since the last key inspection all resident’s care plans had been transferred onto Southern Cross paperwork. We saw that care plans were stored in the main office. They told us that turn charts were held with the person so if they are cared for in bed the charts stay in the bedroom and if they are in the lounge the charts are kept by the side of the chair. During the site visit we noted that these turn charts were actually stored in the dining room on one of the dining tables and not in fact with the resident. Personal information relating to residents should be appropriately stored. This is to minimise the risk of confidential information being accessible to anyone visiting the home. They told us that they have placed focus on the care planning and recording and keeping timely records. We saw that some of the daily notes kept by staff contained repetitive and general statements such as ‘all needs met’. Handover was carried out using a communication book. They told us that at each shift a member of staff is allocated to be responsible for turn charts etc to ensure they are completed. Risk assessments are completed around areas such as falls, pressure areas and nutrition. We saw that these were generally well-completed and kept under review. Staff were trained in manual handling and satisfactory numbers of hoists are available to transfer residents safely. We looked at medication records. These were generally kept well but an issue of serious concern was found. Staff responsible for administering medication Avondale DS0000006694.V368038.R01.S.doc Version 5.2 Page 12 had signed the administration record for three residents as not requiring their teatime medication. This was seen at lunchtime several hours before the medication was actually due. This poses a risk to resident’s of them not receiving the medication they need at the right times or having the opportunity to choose if they wished to take this medication or not. Medication must not be signed for in advance of it being administered to the resident. Refresher training should be offered to this member of staff. We suggested that this was a safeguarding issue and a referral was made using the home’s safeguarding procedures. Residents told us “If I needed medical support the place would contact the doctor” and “the doctor came to see me today”. One resident recently discharged from hospital told us “I am glad to be home.” Avondale DS0000006694.V368038.R01.S.doc Version 5.2 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. 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. Residents are able to maintain contact with family and friends. Residents have a choice of varied, well-balanced meals but the home offers a limited range of activities. EVIDENCE: One resident told us “I used to go out in the garden but not anymore – I don’t want to”. The cook told us that she has been at the home 13 years and knows resident’s likes and dislikes. The meal on the day of the site visit was fish or meatballs chips and peas with bread and butter. We saw that mealtime was a positive occasion and an opportunity for people to talk and interact without being interrupted. The standard of meals had improved since the last inspection. Residents told us that they enjoyed the food offered with comments including “very good”, “good”, “not bad at all” and “the cook is very good”. Avondale DS0000006694.V368038.R01.S.doc Version 5.2 Page 14 We saw staff sitting with residents helping them to eat. This was done in a sensitive manner. The dining area was quiet and the meal unhurried. The dining room was a pleasant environment. Tables were set with condiments, placemats and linen napkins. We saw jugs of fruit juice were available for residents on each table. The menu was displayed but was written in very small print. It is strongly recommended that the menu be produced in larger print to enable residents to read it and make a choice. Residents told us “I expect they would make something else if I didn’t like the meal but I eat everything they cook so I have never asked, I am sure they would make an egg or something.” Residents told us in survey forms “the meals are quite good”, “Meals are alright” and “I like the meals”. They told us that each day sufficient food is prepared so that residents can choose either meal option at the table. They told us that residents were previously asked the day before but this was not successful as people sometimes forgot what they had ordered. This method offers a greater level of choice for residents. They told us they have had a relatives meeting and asked for suggestions on how to improve things. This included revisiting any old concerns that people feel have not been dealt with. They told us they would look back at how they have been investigated in an attempt to reassure people. Relatives or friends told us in survey forms “they do well with entertainment and caring in general” and another said, “they do well with frequent checks on residents and informing relatives of activities.” They told us that the activity organisers post was vacant and as a result there were limited activities at present. They told us that interviews had taken place and they have appointed someone to the post but they are waiting for references. One resident told us in a survey form “there are no activities to do.” Another told us during the site visit “there is not much to do here”. During the two days of inspection we did not observe any activities taking place. We saw staff were in lounges with residents chatting. There is an opportunity for the new activity organiser to develop a social care plan and staff could also be much more involved in providing this important aspect of residents care. The activities co-ordinator when in post should be more involved in organising and supporting staff to deliver activities. This is particularly important for those people who spend a lot of time in their rooms and for individuals with dementia. Avondale DS0000006694.V368038.R01.S.doc Version 5.2 Page 15 Avondale DS0000006694.V368038.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are confident that their complaints will be acted upon. The home has policies and procedures in place to safeguard residents from abuse. EVIDENCE: They had a complaint procedure that residents were aware of. One person told us in a survey form “if not happy I would go to the manager”, “I know how to make as compliant if I had anything to complain about”, “not sure who I would speak to” and “speak to another resident which is also a friend”. The manager said he operates an open door policy and relatives/visitors, staff and visiting professionals to the home are encouraged to raise any concerns or complaints. Records are kept of any concerns or complaints received and we saw that there had been no formal complaints made since the last inspection. The manager told us that one family complained that their relative was not being assisted to put their hearing aid in. To solve this problem it was agreed that a short-term notice be put up in the resident’s bedroom to prompt staff and remind them to put the hearing aid in. Avondale DS0000006694.V368038.R01.S.doc Version 5.2 Page 17 We saw an incident during the site visit that we felt was a safeguarding issue and suggested that a referral be made. As previously stated a member of staff had signed several hours in advance that three residents did not require their teatime medication. This act of omission has the potential to compromise the health and safety of residents. It was of concern that the member of staff who was a qualified nurse thought this action was acceptable. As previously stated this incident was referred to Safeguarding. They told us that they are much happier with staff’s understanding of abuse. An example of this is that a member of staff reported what they felt was the inappropriate moving and handling of a resident. They told us they have internal policies and procedures for the Protection of Vulnerable Adults (POVA). They told us that they had spoken to the safeguarding co-ordinator for Salford who will be arranging safeguarding training for the staff. They said that staff are keen to learn. Avondale DS0000006694.V368038.R01.S.doc Version 5.2 Page 18 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. The residents lived in a safe and well-maintained environment including good standards of hygiene. EVIDENCE: People spoken to were happy with the environment. Comments from individuals included “its good”, “my room is ok” and “fine”. We saw that the home generally provides a pleasant and well-maintained place for people to live. The people living there can easily identify bathrooms and toilets. We saw that a number of bedrooms had been redecorated and that neutral colour schemes had been used. This was particularly good for those residents who have dementia. Hallways had been decorated on the ground floor and the lounge and dining room had also been re decorated. Avondale DS0000006694.V368038.R01.S.doc Version 5.2 Page 19 We saw a sample of residents’ bedrooms these were clean tidy and nicely decorated. There was evidence that resident’s had brought some personal belongings with them and those residents spoken to said that they were very happy with their rooms. They told us that the domestic assistant had left and staff from another Southern Cross home was providing domestic cover. The dining room was bright and airy with a relaxed comfortable atmosphere. This was located next to the kitchen and staff served the meals to the table pre-plated from the kitchen. We saw liquid soap and paper towels were provided in toilets and stocks of plastic aprons and protective gloves were provided in a variety of sizes. This was to meet the individual needs of staff and minimise the risks of infection. They told us they are carrying out an infection control audit and that infection control training was planned. We saw a number of residents sitting in recliner style chairs. This restricted their movements. It was recommended that risk assessments be carried out that take into account the implications of the Mental Capacity Act 2005. Avondale DS0000006694.V368038.R01.S.doc Version 5.2 Page 20 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. There are adequate numbers of staff on duty with the skills and knowledge to meet residents’ needs the recruitment procedures are robust and protect residents. EVIDENCE: Staffing rotas that showed that there was enough staff to meet resident’s needs. On the day of the site visit there were four care staff and a trained nurse on duty. Also on duty was the homes administrator, the manager the new deputy undergoing induction, the cook and a handy person. Staff spoken to said that they had access to training. Staff are offered training in a number of topics such as manual handling, medication, fire safety, First Aid, and Protection of Vulnerable Adults. Future training in the Protection of Vulnerable Adults was planned but the date was not yet confirmed. The staff files had been reviewed since the last inspection. We saw evidence on staff files to show that staff were given a copy of their job description detailing their roles and responsibilities. We saw that some newly recruited staff had been issued with Southern Cross contracts. They told us that staff were allocated specific residents to care for and that this encouraged staff to take responsibility and accountability for their role. Avondale DS0000006694.V368038.R01.S.doc Version 5.2 Page 21 Dementia care training had taken place on the morning of the site visit. This was provided by the manager who had relevant experience in providing dementia care training. They told us that all staff would be receiving this training including the cook who will be involved with the dietary aspect of dementia. A general staff meeting was held after the training and staff told us the training was thought provoking. They told us that a domestic assistant had been employed but had not returned to work. They had been using domestic support from another Southern Cross home whilst they re-advertise the post. They told us that the handyperson covers as domestic at weekends so the home always has domestic support. Staff files had copies of documents to verify the person’s identity. It was recommended that the manager sign and date the photocopy to indicate that they have seen the original documents. We saw on one staff file that although they had current experience of working in a care setting they had not given this as a referee and had in fact taken references from non-related employments. It is strongly recommended that where the applicant has worked in a care related setting references should be taken from this source. Residents and their relatives or friends commented in survey forms “they always have the skills and experience” and “they could improve the level of English spoken by staff.” Avondale DS0000006694.V368038.R01.S.doc Version 5.2 Page 22 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): 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 home that was being well managed and run in their best interests. EVIDENCE: The project manager who was in day-to-day charge of the home at the time of the inspection has considerable knowledge and experience of the needs of older people and of running a care service for older people. They had a good understanding of the conditions and illnesses that are associated with old age and was able to address such issues quickly, benefiting the residents. They told us that a new manager for the service had been interviewed and safety checks were being carried out prior to them taking up the post. Avondale DS0000006694.V368038.R01.S.doc Version 5.2 Page 23 The manager has showed a good understanding of the areas of weakness and there is a good capacity for the service to continue to improve. Staff commented on the new manager “they are brilliant you can go and talk to them about anything”. They also told us “it has been smashing with these here, we are getting new staff we used to have a lot of agency staff but they don’t know the residents – some of them are really good but there are some who are not” “it is much better for the residents now”. Another told us “it is a bit stressful at the moment lots of different people coming in and inspecting us”. The manager reported that regular staff supervision was provided and all staff completed an induction period. This covered care planning, handover, shift planning, roles and responsibilities and training & development The manager was aware of the Mental Capacity Act 2005 and its implications in relation to helping residents to make decisions that affect their lives. It is recommended that the home’s policies, procedures and working practices be reviewed to reflect the implications of the Mental capacity Act 2005 this is particularly important in relation to handling residents money. An electronic banking system, which was interest bearing, was available for residents who are supported with managing their finances. They were able to provide residents with up to date statements of their account. They told us that Southern Cross audited the accounts. We saw records to show that health and safety checks take place to make sure people are kept safe. A QA survey has been carried out recently. They told us that they intend to produce a wall chart with what they do well, what they do not do well and what they could do better. They also intend to analyse the results and produce an action plan that will be forwarded to the commission. Avondale DS0000006694.V368038.R01.S.doc Version 5.2 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 N/A DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Avondale DS0000006694.V368038.R01.S.doc Version 5.2 Page 25 No 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 OP7 Regulation 13 (2) Requirement 1. Where residents have been assessed as “at risk”. The care plan must clearly demonstrate the action required by staff to minimise these risks. Medication must be administered in exact accordance with the prescribers’ directions in particular and in order to protect residents’ health and safety medication must not be signed for as not required several hours before the medication is actually due. Timescale for action 28/08/08 2. OP9 13 (2) 28/08/08 Avondale DS0000006694.V368038.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations 1. It is recommended that all residents care plans are developed on a person centred approach and include details of social needs. Care plans need to give specific information about how the person likes the care and support to be delivered. 2. It is recommended that personal information relating to residents should be appropriately stored. 3. Daily notes should be reviewed to make sure that good quality useful information is being recorded. 4. Personal information relating to residents should be appropriately stored. 1. The ‘getting to know you’ document should be used to devise a programme of activities that will stimulate and motivate the residents and meet their individual hobbies and interests. It is strongly recommended that to orientate residents during mealtimes the daily menu should be printed in a format that is accessible to all residents. 2. OP12 3. 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