Inspection on 06/08/06 for Avondale

This inspection was carried out on 6th August 2006.

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

The inspector 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 17/07/08

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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Avondale 152 New Lane Eccles Manchester M30 7JB Lead Inspector Judith Morton Unannounced Inspection 6th August 2006 14:00 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.V307351.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.V307351.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 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.V307351.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. 1st November 2005 Date of last inspection Brief Description of the Service: Avondale provides nursing and personal care for up to 36 elderly service users. 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. On 7th August 2006 the manager stated that the weekly charges for living at Avondale were as follows: Salford and Trafford Social Services funded residents, £ 310.17 low dependency and £355.52 high dependency residential. There is a top up fee for people requiring nursing care, which is: £40.00 minimal needs, £83.00 medium needs and £133.00 high dependency nursing care. Additional charges are made for newspapers, toiletries, clothes, hairdressing and private chiropody. Avondale DS0000006694.V307351.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit, part of the key inspection for this service, took place over seven and a half hours, spread over two days, on 06/08/06 and 08/08/06. As the first day of the visit was a Sunday, a Registered General Nurse (RGN) was in charge and assisted with the site visit. The Registered Manager was available for the second day of the visit and for feedback. Three residents files and two staff files were checked, together with other documentation, such as staff rotas, training records, and maintenance records. Two visitors, six staff, four residents and a district nurse were spoken with and four questionnaires were returned to the Commission for Social care Inspection. The comments are included in the report. What the service does well: What has improved since the last inspection? What they could do better: More regular, stimulating activities should be provided for the residents to ensure that their physical and mental health needs are fully met. Activities should take place, making more use of other areas of the home, so that residents are encouraged, and given reasons for moving about the home, giving them exercise and changing their environment. Avondale DS0000006694.V307351.R01.S.doc Version 5.2 Page 6 The staff should involve the residents in the writing of their daily record and record their views on how well they feel their needs have been met. 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 DS0000006694.V307351.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.V307351.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 & 5. Standard 6 does not apply. Quality in this outcome area is good. This judgement has been made using available evidence and a visit to the service. The information available for residents and potential residents would help them to know what services are provided at Avondale and whether the home would meet their needs. EVIDENCE: The Statement of Purpose and Service User Guide were two separate documents. They both contained sufficient information available for residents, and potential residents, to know what services are provided at Avondale and whether they would meet their needs. Each were produced in a large, bold print and these were held as the master copies for photocopying should they be required. There was also a copy of the findings of the last inspection produced in large bold print. The manager said she would visit potential residents to conduct an assessment of her own to ensure Avondale could meet their needs. These assessments Avondale DS0000006694.V307351.R01.S.doc Version 5.2 Page 9 were seen on all of the files viewed. There is a document called ‘getting to know you’, which is detailed and gives staff a picture of the resident before the need for them to move into residential care. The manager confirmed that prospective residents and their families were free to visit Avondale so that they could assess and decide whether the home was suitable for them. Avondale DS0000006694.V307351.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence and a visit to the service. The improvements in recording in the residents’ files shows that the care needs are being met and how staff are achieving this. EVIDENCE: Four residents’ files were checked. Two had residential needs and two had nursing needs. There was an individual plan of care for each of the four residents’ files seen. The plans had been devised from information from the initial and ongoing assessment. Both the assessment and care plans had been completed with, and were signed by, the resident and/or their family. The care plans were being reviewed regularly and changes were being made when appropriate. The manager had devised a sample file for staff to follow when making up a new file for a resident so that they can be certain they are including all the documentation required. Avondale DS0000006694.V307351.R01.S.doc Version 5.2 Page 11 The daily recordings being made by staff had improved as regards to the detail being included and showed more clearly the care that had been given against each of the care needs identified. The manager and staff might consider involving the residents more closely, whenever possible in their daily record and include their view on how they feel the care has been delivered and how they have enjoyed their day. (See recommendation 1) Risk assessments were on file and reviews of these and the care plans were being carried out monthly. On the review form it asked if this had been discussed with the family and if it had been discussed with other professionals. Staff had written, ‘yes’. It is important to know who the issues have been discussed with, their name, and designation if appropriate, should be stated and the people involved should sign the form to confirm that it has been discussed with them. (See recommendation 2) There was no evidence of checks being made on the residents throughout the night although staff were recording each morning, whether the residents had slept well and what care, if any had been given to the residents. A form should be produced so that the night staff record and sign that they have checked on each resident throughout the night at the frequency described in their care plan and what care they have given, if any. (See recommendation 3) There were records on the files indicating when health professionals had visited each of the residents and included a brief description of the reason for the visit and outcome. It was clear from the recordings, which included GPs, district nurses, community psychiatric nurses, tissue viability nurses, social workers and chiropodists, that resident’s health care needs were being well met. The district nurse, who said she has visited the home for a long time, said that the home was generally very good, staff seem caring and she gets on well with them, although communication can occasionally be a problem. The medication administration records (MAR), storage and administration procedure was checked. The medical room where the trolley was stored securely was clean and tidy. The medication administration records (MAR) had been signed appropriately and codes were being used when necessary to indicate why a drug had not been taken. The residents spoken with all said that they liked the staff. One resident said that they were very kind and described how one member of staff would come up to her room to say prayers with her occasionally. Avondale DS0000006694.V307351.R01.S.doc Version 5.2 Page 12 The staff were overheard talking with residents in a calm manner and giving the residents time to respond. A few of the residents returned to their room during the day and three residents were being nursed in their room. The staff were also seen and overheard knocking on residents doors before entering their room. Avondale DS0000006694.V307351.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is adequate. This judgement has been made using available evidence and a visit to the service. A greater variety and frequency of activity would provide the residents with stimulation, exercise and a change of environment, which in turn would maintain their social, emotional and physical good health. EVIDENCE: There were a small number of regular planned activities arranged. A notice of these was on display in the entrance hall by the lounge. They included an entertainer who visits fortnightly and sings, encourages residents to dance and play musical instruments. Two relatives spoken with said that they had observed activities, such as armchair exercises and singing, being undertaken in Avondale during their visits. The residents’/relatives’ questionnaires received by the Commission for Social Care Inspection all said that they felt there were not enough activities at Avondale. Past relatives meetings also have it recorded in the minutes that relatives would like there to be more activities. Avondale DS0000006694.V307351.R01.S.doc Version 5.2 Page 14 An increase in activities, that do not always rely on staff time, must be provided for residents to ensure their continued mental and physical good health. (See requirement 1) During both days of the site visit the residents were largely sitting in the lounge, except for meal times when they would go into the dining room. The lounge upstairs and the smaller lounge downstairs were both empty on the first day of the visit. On the second day there were three residents using the small lounge downstairs. More use should be made of the other areas of the home and activities could be arranged in these areas to encourage residents to move about the home more freely. The residents’ ‘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. The residents should be encouraged to choose where they would like to go for outings but leaflets or photographs of local attractions may have to be provided to them to help them to make a decision. A leaflet/photographic resource directory should be produced to assist residents in making choices of outings/activities. (See recommendation 4) Avondale DS0000006694.V307351.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence and a visit to the service. The increase in recorded detail in the resident’s files has enabled complaints to be more thoroughly investigated and systems for continued improvement to be put in place. EVIDENCE: There had been two complaints to the Commission for Social Care Inspection since the last inspection. The manager provided all of the information requested for the complaint to be investigated and new systems were put in place to ensure certain situations could not re-occur. For example, agency staff will not be on the rota at weekends, the homes own bank staff will cover at weekends, no new residents will be admitted to the home over a weekend, unless pre-arranged with the manager. Good recording in the residents’ files had enabled the complaints to be thoroughly investigated. The recording of complaints, who had investigated it, how it had been investigated and the outcome, were all recorded in detail. Staff were aware of the Protection of Vulnerable Adults policy and training was provided to all members of staff, including domestic and kitchen staff, in adult abuse awareness. All visitors to the home were requested to sign the visitor’s book. Avondale DS0000006694.V307351.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 22, 24 & 26 Quality in this outcome area is good. This judgement has been made using available evidence and a visit to the service. Avondale provides the residents with comfortable living, which is clean and well maintained. EVIDENCE: Avondale was being well maintained. The maintenance man makes regular checks on the fixtures and fittings within the home and repairs or replaces these as and when necessary. The carpets in the lounge, dining room and corridors downstairs were to be cleaned the following week, this was seen in progress by the inspector on a visit to the home to collect paperwork. The residents can access a large lounge or a smaller, quiet lounge on the ground floor. Avondale DS0000006694.V307351.R01.S.doc Version 5.2 Page 17 On the first floor there is a further lounge with a small area off it where residents can make themselves a drink. Residents who smoke can also use this lounge. Although the residents’ bedrooms did not benefit from ensuite facilities, there were sufficient bathrooms, a shower room and toilets within the building to meet the needs of the residents. These are equipped with rise and fall bath chairs to aid entry into the bath and grab rails are fixed next to the toilets. Commode chairs were available in resident’s rooms for use at night. There is also a passenger lift to the first floor. The residents’ own rooms were individual and had been furnished to varying degrees with ornaments, pictures, photographs and small pieces of furniture from their own home. The soft furnishings were co-ordinated in each room. Avondale provides the residents with comfortable living, which was clean and well maintained. Avondale DS0000006694.V307351.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence and a visit to the service. The thorough recruitment practices being followed, together with the training provided to staff, would further ensure the safety of the residents. EVIDENCE: There are nursing staff and residential care staff employed by the home to meet the different needs of the residents. Staffing levels on both days of the site visit were sufficient to meet the needs of the residents. They were compared with the staffing rota and were accurate. A registered general nurse undertook the manager’s role at weekends, as the manager does not work at weekends. The registered nurse who assisted with the inspection on the first day was knowledgeable about the home and was observed giving staff direction. The two newest staff member files were checked. The files contained all of the information required to confirm their identity, experience, qualifications and viability. The manager had also obtained work permits, visas and national insurance numbers for any staff coming from abroad. There is an induction programme for all new staff. This covers essential training and policies to ensure that the staff can start to provide a good quality of care to the residents. Certificates of training are held on the staff files. Avondale DS0000006694.V307351.R01.S.doc Version 5.2 Page 19 Mandatory training and courses specific to the client group are also provided regularly. Because of the changing needs of the residents, the manager should consider sourcing and providing the staff with training in the management and care of people with dementia and defusing challenging situations. (See recommendation 5) Other training undertaken includes, awareness of Parkinson’s and Huntington’s conditions, prevention of pressure sore, infection control, medication and occupational health. The administration staff member is undertaking NVQ Level 3 in business administration and the manager has successfully completed the Certificate in Equality and Diversity. Four residential care staff currently hold NVQ level 2 and a further three staff are undertaking the course. Staff meetings take place regularly and the minutes are held on file in the office. Additionally, the manager includes a copy of the staff meeting minutes in each envelope containing the staff pay slips. The manager will call an impromptu meeting to update staff practice and keep them informed of change in policy or procedures. The manager has introduced an allocation sheet for staff so that those residents with the highest level of care needs have a key member of staff responsible for their care each day. This ensures that staff are accountable for all needs to be met. Avondale DS0000006694.V307351.R01.S.doc Version 5.2 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38 Quality in this outcome area is good. This judgement has been made using available evidence and a visit to the service. The manager’s clear direction and support to staff, together with the supervision provided ensures that the staff continue to develop their practice and provide a high level of care to the residents of Avondale. EVIDENCE: The manager has devised a number of systems of recording so that she can keep track of all of her responsibilities and make sure they are completed. Staff spoken with on both days of the site visit were all positive about the manager. One member of staff said she felt she got on well with the manager; she liked her and felt it was important for staff to get on with the manager and feel they can approach them with anything. Avondale DS0000006694.V307351.R01.S.doc Version 5.2 Page 21 Another member of staff, who had had some personal difficulties, said that the manager had been extremely supportive and had continued to be so on the staff members’ return to work. The manager has shown a willingness to listen and learn from the residents and relatives. Regular meetings are held and the minutes recorded. It is clear from reading the minutes that where areas of dissatisfaction had been identified the manager had improved them to the satisfaction of all involved. The inspector made a number of suggestions to the manager that had been received on the questionnaires returned to the Commission for Social Care Inspection. The manager recorded the suggestions and agreed that they would be beneficial to the residents, such as providing linen baskets in bedrooms so that residents, particularly those who are becoming confused or forgetful, do not return their worn clothes to the wardrobe. (See recommendation 6) The manager sends questionnaires to relatives, staff, residents and visiting professionals on a quarterly basis to obtain their views on how the home is being run. This makes sure that those who are unable to attend the meetings are still able to contribute their views. The manager should produce a report of the findings from the questionnaires on an annual basis and include an improvement plan for the home devised from any concerns, comments or complaints generated from the questionnaires. (See recommendation 7) Staff were being supervised on a regular basis. This covered working practice, policies and procedures and identified training requests and needs. Supervision was being recorded and both parties signed the supervision record. The manager had spoken with the residents about what they should do in the event of a fire and a fire drill had been carried out successfully. Fire safety training and fire prevention equipment testing were taking place regularly. Regular checks of emergency lighting were also made. The fire officer’s report of 26th June highlighted a small number of areas for attention. These had been completed and signed off by the fire officer on a return visit on 30th June. The manager said that fire officer said he had never visited a home so soon after the work had been identified and the repairs had met his approval. The accident book was being completed appropriately. Avondale DS0000006694.V307351.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X 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 3 3 X 3 3 X 3 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 3 X 3 Avondale DS0000006694.V307351.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? NO 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 OP12 Regulation 14 &15 Requirement An increase in activities must be provided for residents. Timescale for action 01/12/06 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 Refer to Standard OP7 OP7 Good Practice Recommendations The resident’s views on how their day has been should be included in the daily records. The name, and designation (if appropriate) of the person involved in any discussion at review of care plans or risk assessments, should be stated and the people involved should sign the form to confirm that it has been discussed with them. A form should be produced so that the night staff record and sign that they have checked on each resident throughout the night at the frequency described in their care plan and what care they have given, if any. 3 OP7 Avondale DS0000006694.V307351.R01.S.doc Version 5.2 Page 24 4. OP12 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. The residents should be encouraged to choose where they would like to go for outings. A leaflet/photographic resource directory should be produced to assist residents in making choices of outings/activities. The manager should consider sourcing and providing the staff with training in the management and care of people with dementia and defusing challenging situations. Linen baskets should be provided in residents’ bedrooms. The manager should produce a report of the findings from the homes’ quality assurance exercise, on an annual basis and include an improvement plan for the home devised from any concerns, comments or complaints generated from the questionnaires. 5 OP30 6 7 OP24 OP33 Avondale DS0000006694.V307351.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection CSCI, Local office 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 DS0000006694.V307351.R01.S.doc Version 5.2 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. 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