Inspection on 20/05/05 for Avondale

This inspection was carried out on 20th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 17/07/08

Avondale 06/08/06

Avondale 01/11/05

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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Avondale 152 New Lane Eccles Manchester M30 7JB Lead Inspector Elizabeth Cooper Unannounced 20 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 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 F55 F05 s6694 Avondale V228702 D200505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Avondale Address 152 New Lane Eccles Manchester M30 7JB 0161 707 2303 0161 707 9153 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) Focus Care Centres LImited Responsible Individual - Mr R McNamara Care home with nursing (N) 36 Category(ies) of Old age, not falling within any other category registration, with number (OP) (36) of places Avondale F55 F05 s6694 Avondale V228702 D200505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1 Up to 36 service users requiring nursing or personal care may be accommodated. 2 One named service user who is under 65 years of age and requires personal care may be accommodated. 3 One named service user who is under 65 years of age and requires nursing care may be accommodated. 4 Minimum nursing staffing levels as specified in the Notice issued under Section 25(3) of the Registered Homes Act 1984 shall be maintained. 5 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. 6 The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. Date of last inspection 29 March 2005 Brief Description of the Service: Avondale provides nursing and personal care for up to 36 elderly service users who require either nursing or personal care. 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 single and double occupancy rooms. The main lounge/dining areas are on the ground floor and a smaller lounge is situated on the first floor. The manager was present at the inspection. She had applied for registration with the CSCI and this was being processed at the time of the inspection. Avondale F55 F05 s6694 Avondale V228702 D200505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. What the service does well: What has improved since the last inspection? What they could do better: Maintenance of essential services in the premises must be improved to ensure that the service users remain safe. Service user plans have been developed and improved in some areas but further developments can be made to ensure that accurate records are maintained. Although the meals were of a good standard, a choice should be introduced into the menu and assistance provided for the chef to ensure that this can place. Avondale F55 F05 s6694 Avondale V228702 D200505 Stage 4.doc Version 1.30 Page 6 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 F55 F05 s6694 Avondale V228702 D200505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Avondale F55 F05 s6694 Avondale V228702 D200505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3 and 4 The home carried out detailed assessments prior to placement and each service user had access to the Service User Guide. Some improvements were needed in respect of the contracts. EVIDENCE: A requirement was made at the last inspection that the Service User Guide must be amended to include the experience and qualifications of the manager and home owner. The timescale for compliance with this requirement had not elapsed at the time of the inspection. However, the home had made the amendments but had inserted them in the Statement of Purpose and Function. The home had identified the error and intended to insert the amendments into the Guide. Not all of the service users had been issued with copies of their contracts with the home although a copy of the standard contract was contained in the Statement of Purpose and Function. This contract needed some amendment to include details of the room to be occupied and the need to add any special requirements for individuals was discussed with the manager. The administrator confirmed that, even though this was her role, she had not issued any contracts since her employment and that service users had been admitted since that time. Avondale F55 F05 s6694 Avondale V228702 D200505 Stage 4.doc Version 1.30 Page 9 The manager carried out all pre-admission assessments and copies of these were stored with the service user’s personal information. The assessments were comprehensive and covered all major activities of daily living. Discussions were held with the manager to expand the information recorded on assessments to include from whom and where the information was obtained. Initial care plans were developed from the information gathered on assessment and full plans were then developed following the first month’s review. Avondale F55 F05 s6694 Avondale V228702 D200505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9 and 10 Service user plans were generally improved although they could be developed further. Health care needs were well met and the residents and relatives were happy with the care provided. Medicines were appropriately stored although records could be improved. Service users were treated with respect and their dignity was well maintained. EVIDENCE: Each service user had an individual plan of care. These varied in detail. A requirement was made at the last inspection that post-admission assessments must be completed in more detail to allow staff to formulate appropriate care plans and information gathered in that process must be incorporated in the plans where appropriate. This had not been fully addressed as some of the plans examined did not contain some of the relevant information available in assessments. However, the timescale for compliance had not expired and the manager was continuing to work with the staff to meet this requirement. The home used bedrails and recognised that these were a form of restraint. Although the home obtained the service user’s or their representative’s consent to use the rails, no form of assessment was carried out to ensure that using this form of restraint was in the best interests of the service user. Avondale F55 F05 s6694 Avondale V228702 D200505 Stage 4.doc Version 1.30 Page 11 Relatives and service users were involved in the care planning process as they were asked to complete a document called “Getting to Know You” with staff if required. This looked at the service user’s life history and specific likes and dislikes. These varied greatly in detail and the information gathered was not always used in the care plans despite being relevant to the service user’s current needs. Improvements were seen in the standard of the daily records although these could be developed further. Reviews were carried out on a monthly basis although these contained little detail and did not indicate whether the interventions stated in the plans were effective. None of the service users accommodated at the time of the inspection had pressure sores although a number had been admitted to the home with open sores. Accidents were recorded on record sheets developed by the home and each record was kept with that service user’s plan. An appropriate accident book was available but not in use. Advice was given to the manager on how to complete these and store the records appropriately as the staff reporting the incident were not completing their personal details as required. A requirement had been made at the last inspection that staff must ensure that they monitor the service user’s condition following an accident. The timescale for compliance with this requirement had not expired. The home used a monitored dosage system for medicine storage and administration. There were some unexplained gaps in the records and advice was given about using the reverse of the medicine administration record (MAR) sheet to pass information onto staff about specific issues such as dispensed medicine that service users had refused. Service users were clearly identified by photographs in some, but not all cases and the manager indicated that photographs would be obtained for all of the service users in the home. Controlled medicines were stored and recorded appropriately and staff checked the stock levels on a daily basis. Service users were treated with respect and staff had an affectionate, friendly relationship with the service users and their relatives. A number of service users were spoken to during the inspection. Each of these service users stated that staff treated them with respect and ensured their dignity was maintained in particular when carrying out intimate procedures or helping them maintain their personal hygiene. Comments such as, ”staff always knock” “I am so happy here” and “staff are very kind and are always asking me if I need things” were made by the service users. The relative spoken to during the inspection stated that she was consulted about her mother’s care, was kept informed about any changes and felt that the staff Avondale F55 F05 s6694 Avondale V228702 D200505 Stage 4.doc Version 1.30 Page 12 were respectful and kind towards her mother. The Inspector observed staff interacting with the residents in a friendly but respectful manner throughout the inspection. Staff were observed sitting with service users and feeding them on an individual basis. An agency nurse was observed standing over one of the service users to feed her. The manager immediately approached her and explained that she must sit down and interact with the service user concerned. Some concerns had been raised by a PCT Nurse Assessor regarding the home running out of incontinence pads over the weekend prior to inspection. This meant that the home was not able to meet the full needs of some of the service users at that time. The home had investigated the problem and had found that staff had been using inappropriate pads for some of the service users and had not followed the assessments. As a result, the manager had provided all staff with detailed information regarding the service user’s continence needs, appointed one senior member of staff as responsible for monitoring the supply and alerting her to the need to reorder and had created an emergency store of pads to prevent any reoccurrence. The home carried out continence assessments on each of the service users following admission and liaised with the incontinence advisor regarding the outcomes. Avondale F55 F05 s6694 Avondale V228702 D200505 Stage 4.doc Version 1.30 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 standard(s) 12,13,14 and 15 The home was welcoming and service users had choices in many aspects of their daily life. Activities needed developing and choices needed to be incorporated in the menus. EVIDENCE: The home had a friendly and welcoming atmosphere. A clothing party had been organised for the afternoon of the day of the inspection and service users were encouraged and enabled to make choices about purchases by the staff. Entertainers came into the home on a regular basis. Service users were not involved in choosing the entertainment. The home did not have an activities coordinator and staff were encouraged to spend time talking to the service users and carrying out activities with them in the afternoons although the manager stated that other duties often meant that staff did not have the time to do this. The home had planned a relatives/service user’s meeting. A requirement was made at the last inspection that dedicated social care staff must be provided for a minimum of 15 hours a week and service users must be involved in the choice of social activities provided. The manager showed the inspector that an interview for an activities co-ordinator had been arranged for the following week. The timescale for compliance with this requirement had not expired at the time of the inspection. Service users spoken to during the inspection stated that entertainers regularly came into the home although they did not choose the type of entertainment provided. One service user Avondale F55 F05 s6694 Avondale V228702 D200505 Stage 4.doc Version 1.30 Page 14 stated that she attended church regularly and a number stated that their friends and family visited regularly. The relative spoken to during the inspection stated that she was welcomed into the home at all times. Notices about the clothing party were seen around the home and some of the service users knew about it in advance. Service users were observed choosing their own clothes. A number of service users told the inspector that they were able to get up and go to bed at a time of their choosing and felt that they had the freedom to do whatever they liked within their limitations. Notices were seen advertising the service user/ relatives meeting and a number of replies from relatives regarding their attendance or otherwise were seen in the office. One of the relatives told the inspector that she had told the manager that she would not be able to attend and stated that she had been made aware of the meeting through the posters. The meals were varied and wholesome. They smelled and looked appetising and there appeared to be little waste. A light meal/snack was served midday and a substantial meal in the evening. No choice of meal was built into the menu. Staff assisted service users to eat in an appropriate manner and a staff presence was maintained in the dining room throughout meal times. The menus were examined and the chef confirmed that only one meal was prepared for the main meal as she did not have any kitchen assistance and would not, therefore have time to prepare so much food in any one day. Service users stated that the food was very good and very tasty. Avondale F55 F05 s6694 Avondale V228702 D200505 Stage 4.doc Version 1.30 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 standard(s) 16 and 18. Staff, service users and relatives were aware of how to complain although the records of complaints could be developed further. The staff were aware of adult protection issues although this could also be developed further. EVIDENCE: The CSCI had received three complaints since the appointment of the manager. One remained under investigation. One complaint had been investigated by the home and was upheld. This concerned a member of staff borrowing money from a service user. The home took appropriate action to address this issue and a report of their findings was sent to the CSCI. The final complaint concerned issues that the home had addressed prior to the complaint being raised with the CSCI and no further action was required as a result of our investigations. The manager was advised that all complaints and concerns must be recorded along with the investigation, outcome and details of the feedback given to the complainants. Service users and relatives spoken to during the inspection stated that they would feel comfortable making a complaint and staff demonstrated an awareness of types of abuse. Training in adult protection had been planned and staff voluntarily stated that they were due to receive this training. The manager stated that the home did not have a copy of Salford’s Adult Protection policy. She was advised that this must be used with the home’s own policies and that their requirements to contact the appropriate authorities first must take precedence over their in-house policies. Avondale F55 F05 s6694 Avondale V228702 D200505 Stage 4.doc Version 1.30 Page 16 The home had not received any complaints that had been investigated using the Protection of Vulnerable Adults (POVA) procedures and no staff had been referred to the POVA list. Service users and relatives were aware of how to complain and issues were regularly raised with staff. These were not recorded as complaints although they were dealt with by the home. Avondale F55 F05 s6694 Avondale V228702 D200505 Stage 4.doc Version 1.30 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 standard(s) 19,21 22 and 24. The home was clean however the inspector did not feel that the premises were maintained safely. (See also, Management and Administration section). EVIDENCE: Copies of a fire service report carried out on 12.04.05 indicated that: all the smoke detectors were out of warranty and required replacing, most of the exit lights needed replacing and the system had not been, but must be maintained. No evidence was available to indicate that this had been addressed although the maintenance manager believed that some of the fire exit lights had been replaced. An immediate requirement was issued to address these issues. A programme of regular maintenance of the fabric and fittings was maintained and records were available for the majority of these. Some redecoration had been carried out since the last inspection. A copy of the fire risk assessment was examined and was found to be comprehensive. This was carried out on 21.04.05. A copy of the Fire Avondale F55 F05 s6694 Avondale V228702 D200505 Stage 4.doc Version 1.30 Page 18 Department’s report from 17.05.04 was examined. The only requirement was that a fire risk assessment must be carried out and this had been addressed. The home’s own fire safety records were examined. These indicated that appropriate monthly and weekly checks were maintained. It was suggested that weekly emergency lighting checks should be maintained until the fire exit lights and smoke detector defects had been successfully addressed. Maintenance of the fire exit signs and smoke detectors must also be included in the safety/maintenance checks following the service findings. Records were seen indicating that regular fire drills and annual fire training had been carried out. The manager stated that fire training was also covered in induction training. A completed induction programme record was examined that supported this. Staff also stated that they received this training on a regular basis. The ceiling in the bathroom identified in the requirement from the last inspection was inspected and was found to have been repaired to an acceptable standard. Service users stated that their rooms were comfortable and well decorated. One service user showed the Inspector her room and expressed her satisfaction at the furnishings and fittings provided. The Inspector observed that the slings had all been stored appropriately and that the hooks used to store the slings had been repositioned to ensure that they did not trail on the floor. 3 height adjustable nursing beds had been provided for those nursing service users who had the most need of them. The manager stated that the home was planning to provide more beds within the next financial year. Requirements made at the last inspection had been addressed. These were: that the ceiling in one of the bathrooms must be repaired and that staff must be instructed in infection control principles regarding the correct storage of hoist slings. Avondale F55 F05 s6694 Avondale V228702 D200505 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 and 30 Staffing levels were sufficient to meet service users needs, recruitment practices were robust and training had been provided in care related areas. EVIDENCE: Copies of staffing rotas were taken and examined. These indicated that the levels complied with the home specific Staffing Notice. The home employed 15 care assistants. Of these 3 had completed NVQ level 2 and 4 were undergoing training. This was confirmed through discussions with the staff concerned. Personnel records were examined for all grades of staff. One staff member did not have 2 references on file however, they had been employed at the home for a number of years and the home had tried, unsuccessfully to obtain references on a number of occasions. The Inspector saw records that demonstrated that the staff member had had supervision and appraisal sessions that demonstrated that they carried out their role appropriately. Avondale F55 F05 s6694 Avondale V228702 D200505 Stage 4.doc Version 1.30 Page 20 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37 and 38 Maintenance records were poor and outdated in some areas. EVIDENCE: A requirement was made at the last inspection that an electrical safety inspection must be carried out and this had been addressed. The certificate had not been issued although there was documentary evidence available to indicate that the inspection had taken place. The maintenance manager indicated that some remedial work was required but that this had not been addressed at the time of the inspection. A warning certificate was issued in December 2004 in respect of the gas systems but there was no evidence to indicate that this work had been carried out. The boilers had been inspected at the same time and remedial work was also required to ensure that they were safe. This had not been addressed. The paperwork available in the home indicated that the lift had not had a Thorough Examination report since 1994. A company independent of the main Avondale F55 F05 s6694 Avondale V228702 D200505 Stage 4.doc Version 1.30 Page 21 service contractor must carry this out on an annual basis. Immediate requirements were issued in respect of the gas, the boilers and the lift. The home certificate and insurance certificate were displayed in the main foyer. Comprehensive monthly Regulation 26 report were submitted by the Operations Manager to the CSCI detailing the findings of her inspection of the home. Avondale F55 F05 s6694 Avondale V228702 D200505 Stage 4.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 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 2 3 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION 2 x 3 3 x 2 x x STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 3 x x x x x 3 1 Avondale F55 F05 s6694 Avondale V228702 D200505 Stage 4.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 op7 Regulation 15 Requirement Risk assessments must be carried out and the stages of the assessment clearly recorded in order to ascertain whether service users need bedrails or otherwise. Timescale for action 20.06.05 2. op7 12 Service users and/or their 20.06.05 representatives must be involved with the care plan reviews. Medicine administration records must be maintained accurately. 20.06.05 3. 4. op9 op8 13 17 sch 4 Staff must complete their 20.06.05 personal details when completing an accident report and the reports must be stored in accordance with the Data Protection Act 1974. An alternative main meal must be included on the daily menus. All complaints must be recorded with details of the subsequent investigation, outcomes and feedback given to the complainant. 20.06.05 20.06.05 5. 6. op14 op16 12 17sch4 Avondale F55 F05 s6694 Avondale V228702 D200505 Stage 4.doc Version 1.30 Page 24 7. op19 23 Proof must be provided that all 27.05.05 smoke detectors that are out of warranty have been replaced, that all exit lights are functioning appropriately and that the smoke detectors and exit lights have been incorporated into the weekly fire safety checks. All remedial work indicated at the last electrical safety inspection must be carried out and evidence of the same forwarded to the CSCI. 20.06.05 8. op37 23 9. op38 23 Thorough Lift Examinations must 27.05.05 be carried out in accordance with insurance requirements and copies forwarded to the CSCI. All remedial work highlighted on the boiler and gas safety inspection report of 9.12.04 must be completed and evidence of this work must be forwarded to the CSCI. 27.05.05 10. op38 23 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 OP2 OP12 OP15 OP18 Good Practice Recommendations Each of the service users shuld be issued with a contract specific to any personal needs, clearly stating the terms and conditions and including the room number. The service users should be involved in choosing the activities available in the home. Extra staff should be provided in the kitchen to enable the chef to provide an alternative to the main menu. The home should obtain a copy of the Local Authority Adult Protection procedures and ensure that they are used when investigating any adult protection complaint. F55 F05 s6694 Avondale V228702 D200505 Stage 4.doc Version 1.30 Page 25 Avondale Commission for Social Care Inspection 9th Floor, Oakland House Talbot Road Manchester M16 0PQ 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 F55 F05 s6694 Avondale V228702 D200505 Stage 4.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. 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