Inspection on 19/01/06 for Avondale Nursing Home

This inspection was carried out on 19th January 2006.

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 Nursing Home 11/09/07

Avondale Nursing Home 06/07/06

Avondale Nursing Home 22/06/05

Avondale Nursing Home 16/11/04

Avondale Nursing Home 21/05/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Avondale Nursing Home 26 Snakes Lane West Woodford Green Essex IG8 OBS Lead Inspector Julie Legg Announced Inspection 09:00 19 & 24th January 2006 th 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 Nursing Home DS0000025947.V272638.R01.S.doc Version 5.0 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 Nursing Home DS0000025947.V272638.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Avondale Nursing Home Address 26 Snakes Lane West Woodford Green Essex IG8 OBS 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) 0208 506 2194 0208 559 0251 Mrs Inderjeet Kaur Ford Ms Elizabeth Ruth Polkinhorn Ms Elizabeth Ruth Polkinhorn Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Avondale Nursing Home DS0000025947.V272638.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd June 2005 Brief Description of the Service: Avondale Nursing Home is a 20 place care home with nursing for older people situated in a residential part of Woodford. The accommodation is comprised of a two storey detached house with purpose built extensions to the side and rear of the property. There is a car park to the front of the house, a small patio area to one side, and a garden to the rear. There are two connecting lounges on the ground floor, along with a utility room, kitchen, staff office, and some of the bedrooms. The remaining bedrooms along with bathrooms and toilets are on the upper floor. There are two double bedrooms, both of which have an ensuite toilet and 16 single rooms many of which also have an en-suite toilet. The home is privately owned by two business partners, who are also jointly registered as the manager. They employ a matron to oversee the day-to-day care of the residents. Avondale Nursing Home DS0000025947.V272638.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over two days and lasted seven hours. The inspector spoke to a number of residents, who were asked about their experience of living at the home. Staff were spoken to about care practices in the home. They were also observed directly and indirectly providing care to residents. Discussions took place with the owners/managers, the matron and the cook. A tour of the home was undertaken, including all of the bedrooms and the kitchen. Residents’ care plans were examined, along with other records, such as staff rotas, menus, the complaints log and staff files. This was the second statutory inspection visit in the inspection programme for 2005/6. Over the course of the two visits, all core standards have now been assessed. Eleven requirements were set at the last inspection and five of these requirements have not been met and have been restated in this report with new timescales for compliance. Further information about unmet requirements can be found in the relevant standard. Unmet requirements impact on the welfare and safety of the residents. Failure to comply by the revised timescales will lead to the Commission for Social Care Inspection considering enforcement action to secure compliance. What the service does well: What has improved since the last inspection? The remaining bedrooms have been redecorated and new carpets fitted. Residents in those rooms were pleased and said they looked homely. Six of the previous requirements have been met. Avondale Nursing Home DS0000025947.V272638.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Avondale Nursing Home DS0000025947.V272638.R01.S.doc Version 5.0 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 Nursing Home DS0000025947.V272638.R01.S.doc Version 5.0 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 Standards 3,4 and 5 were not tested on this visit. However the judgement from the last inspection was that residents have their needs assessed prior to moving into the home and at the stage of admission, the residents and the relatives know that the home can meet their needs. Residents and their relatives have the opportunity to visit the home prior to admission and assess the quality of care. Prospective residents and their relatives have the information they need to make an informed choice about living at the home. The home does not provide intermediate care, therefore standard 6 is not applicable. EVIDENCE: Standards 3,4 and 5 were not specifically tested on this visit, as there were no outstanding requirements in relation to these standards. At the time of the last inspection these standards were assessed as met. These standards will be retested at a future inspection. Avondale Nursing Home DS0000025947.V272638.R01.S.doc Version 5.0 Page 9 There is a Statement of Purpose and a Resident’s Guide, both of which needed a minor amendment now there are two, rather than three double rooms. On inspecting these documents, the amendments have been completed. This requirement has now been met. The home does not provide intermediate care. Avondale Nursing Home DS0000025947.V272638.R01.S.doc Version 5.0 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 and 10 Residents’ health and personal care needs are set out in individual care plans, but inconsistencies and omissions in recording of the care to be given and being provided, could mean that they are not being fully met. Staff are following the home’s medication policies and procedures to ensure safe administration of medication. Residents are treated with respect and the arrangements for their personal care ensures their right to privacy is upheld. EVIDENCE: Individual care plans were available for each of the residents. Six of these care plans, including risk assessments, were examined as were the daily log sheets. The inspector also spoke to four residents who gave their views and staff were observed carrying out their duties. The home has an assessment, care planning and recording system in place for the provision of nursing and personal care. Residents’ needs are set out and how these are being met by both nursing and care staff should be recorded in Avondale Nursing Home DS0000025947.V272638.R01.S.doc Version 5.0 Page 11 the daily log, which is part of the care plan documentation. On examination of the care plans, gaps and inaccuracies were identified. One resident required a pureed diet. This was not identified in her care plan. Another resident had her arm in plaster in October last year. This had been identified in her care plan, however the plaster was removed six weeks later but the care plan had not been reviewed. Residents’ weights are not been recorded on a regular basis. There was little evidence that any of the care plans had been evaluated monthly or when a change in the residents’ needs was identified. On examining the daily logs, there was evidence that there were gaps in the recordings. The manager confirmed that staff should be completing these on every shift. At the last inspection it was noted that advice given by the Tissue Viability Nurse had not been transferred to the care plan or the daily log. This has now been rectified. However because there are still inaccuracies and gaps in the care plans and the daily logs, and the regular evaluation of the care plans is not taking place, the registered provider cannot demonstrate adequately that they are meeting the residents’ current needs. This is Requirement 1. A requirement was set at the last inspection that the registered provider must ensure that there is a comprehensive policy and procedure in place for those residents who may be able, and wish, to self-medicate. This policy had to include how medication retained by the resident will be stored. This has now been completed. This requirement is now met. The inspector examined six residents’ risk assessments. There was little evidence that the risk assessments were being reviewed monthly or when a new risk or change is identified. Risk assessments regarding moving and handling, pressure sore care, and aggressive verbal and physical behaviour have not been reviewed for at least six months and in some cases over a year. This lack of robust monitoring, could be putting residents and staff at risk. This is Requirement 2. There was no evidence from residents’ files that six monthly reviews were taking place. The manager must ensure that the home completes reviews on each resident where all interested parties such as the resident, relative, social worker, can give an opinion as to whether the home continues to meet the residents’ needs. This is Requirement 3. A requirement was set at the last inspection, as the inspector observed two incidents were a resident’s privacy and dignity was compromised. The inspector spoke to the manager who stated that the member of staff had been spoken to formally and that there had not been a reoccurrence of the incident. Residents who were spoken to stated that staff treated them very well and respected their privacy and dignity. One lady stated that“ the staff were very kind and nothing was too much trouble”. Staff were observed talking to residents respectfully and were observed knocking on residents’ bedroom doors before entering. This requirement is now met. Avondale Nursing Home DS0000025947.V272638.R01.S.doc Version 5.0 Page 12 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 and 15 Standards 13 and 14 were not tested on this visit. However the judgements from the last inspection were that residents maintain contact with their family and friends as they wish. Residents are assisted to exercise choice and control over their lives. Residents’ social and recreational needs and wishes are identified in their care plans, but there are no records to demonstrate that the registered persons give a high priority to this important area of the care of older people. The registered persons offer a varied menu and residents have a choice in the meals provided, however the menu must show a true reflection of the meals being offered. EVIDENCE: Standards 13 and 14 were not specifically tested on this visit, as there were no outstanding requirements in relation to these standards, which were assessed at the last inspection as met. These standards will be re-tested at a future inspection. At the last inspection a requirement was set that residents’ social and recreational interests are identified and met, as far as possible. A record of activities must be kept, which clearly shows each resident’s involvement in Avondale Nursing Home DS0000025947.V272638.R01.S.doc Version 5.0 Page 13 each activity. Care plans were examined and residents were asked their views, and this aspect of care was also discussed with the manager. Care plans examined showed that residents’ interests were recorded and two of the residents stated that they were happy with the level of activity. The manager reported that activities, such as, music and movement, games, bingo and reminiscence sessions regularly take place. However there were no records in the daily logs to evidence how the residents spend their day. Residents that spoken to stated that there wasn’t a lot of activities and they did not happen very often. One resident said she would like to go out to the shops. The inspector spoke to the manager about individual activities for the residents being undertaken as well as group activities. This previous requirement is being taken forward with a new timescale. This is Requirement 4. The current four weekly menu was examined and discussed with the cook. There is a choice of meals and the cook said he would cook something different if the resident did not like either of the choices. On the day of the inspection the lunchtime menu did not correlate with the meal that was being cooked. The cook stated that he had spoken to the residents who had asked for roast chicken. Residents, who were spoken to, confirmed that they had said that they would prefer roast chicken. It is good that residents’ choices are respected, however the registered person must ensure that when there is a change in the menu this must be recorded. This is requirement 5. Avondale Nursing Home DS0000025947.V272638.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The registered persons are not registering all of their complaints nor reporting all incidents to the Commission. Therefore the Commission cannot be confident that residents and relatives’ complaints and concerns are being listened to and acted upon. The registered person has a satisfactory policy and procedure regarding the allegations of abuse, however the manager must ensure that all staff attend training inn adult protection/abuse awareness to ensure that there is an appropriate response to any allegations of abuse. EVIDENCE: The registered persons have a complaints procedure which specifies how people can make a complaint and who will deal with them. The complaints log was examined and there has been some improvement in the logging of these, however a resident’s daughter had made a complaint, four days prior to the inspection and this had not been logged. The manager stated that as the complaint had been dealt with, she did not feel it needed to be entered in the complaints log. The inspector advised that all complaints needed to be logged and whether the complainant was happy with the outcome. This is was a previous requirement, which has been set with a new timescale. This is Requirement 6. At the last inspection a requirement was set regarding the legal requirements to notify the Commission of significant events. The managers and the matron were only reporting the death of a resident and not of any other significant Avondale Nursing Home DS0000025947.V272638.R01.S.doc Version 5.0 Page 15 events. Regulation 37 requires all registered providers to notify the Commission about significant events that may adversely effect the well-being or safety of any resident. Records held by the Commission and records that were checked within the home show that other than the death of a resident other significant events such as, serious falls and visits to Accident and Emergency are still not being reported. This was discussed with one of the managers and the matron, who stated that they had misplaced the form and that again they thought it was only for the notification of the death of a resident. The reporting of incidents is an important monitoring tool for both the home and the Commission. This matter is of some concern as this had been an issue that had been discussed at the last inspection and a requirement was set, which has not been met. This is Requirement 7. There is a written policy and procedure for dealing with allegations of abuse and whistle blowing. The home also has a copy of the local authorities (Redbridge) documentation on abuse. The registered persons carry out inhouse training as part of all new staff’s induction programme but on inspection of staff files not all of the staff have attended ongoing formal training on adult protection/abuse awareness. This is Requirement 8. Residents that were spoken to said they were happy with the care they received and two of the residents said they would speak to one of the managers if they were unhappy. The inspector spoke to staff who were clear on the different forms of abuse and that they would report any incidents to the manager or the matron. Avondale Nursing Home DS0000025947.V272638.R01.S.doc Version 5.0 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): 19,20,21,22,23,24, and 26 The home is clean, pleasant and spacious with access to indoor and outdoor communal facilities, which adequately meet the needs of the residents. There are sufficient, suitable toilets and bathrooms for the number of residents. Specialist equipment such as hoists, mattresses and walking aids are available to meet the needs of the residents. Residents’ bedrooms suit their needs. EVIDENCE: The registered persons has an ongoing redecoration programme and since the last inspection, some of the rooms have been redecorated and new carpet fitted. The registered person employ a handyman, who undertakes a rolling maintenance programme to ensure that the residents live in a comfortable and safe home. The inspector undertook a tour of the home during the inspection. There are two comfortable lounges, which are also used for mealtimes. All of the residents’ bedrooms are appropriately furnished and have family Avondale Nursing Home DS0000025947.V272638.R01.S.doc Version 5.0 Page 17 photographs, ornaments and other small items of furniture that the residents have bought from their own homes. Some of the bedrooms have electrically operated beds, which ensure the safety and comfort of the residents. There are sufficient toilets and bathrooms, each bathroom has an assisted bath and all of the toilets are wheelchair accessible. The kitchen was found to be clean and all foods appropriately stored. The home is cleaned on a daily basis and throughout the inspection all areas of the home were found to be clean and tidy. There are adequate control systems in place to ensure that the home is free from any offensive odours. Avondale Nursing Home DS0000025947.V272638.R01.S.doc Version 5.0 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 and 30 Staffing levels are satisfactory and there are sufficient staff on duty, however the training and the skills mix of the care staff must be reviewed to ensure they can meet the individual needs of the residents. The home’s recruitment policy and procedure is not always being followed and appropriate checks are not always undertaken. Therefore the Commission cannot be confident that service users are protected by the recruitment practice. EVIDENCE: The home has a relatively stable workforce. On the day of the inspection, staffing levels were seen to be appropriate to meet the needs of the residents. During the day there are four care staff and a qualified nurse, at night there is one care staff and a qualified nurse. Staff rotas were also examined and the rota correlated with the number of staff on duty on the day of the inspection. The rota also identified which proprietor/manager was responsible for the home that day. The home also employs a domestic, a cook and a handyman. Four staff files were examined which identified that the registered persons are not always undertaking stringent recruitment checks. One file had one written reference and a verbal reference instead of two written references. Another file Avondale Nursing Home DS0000025947.V272638.R01.S.doc Version 5.0 Page 19 indicated significant gaps in the applicant’s employment history, which were not followed up. This is Requirement 9. Some of the staff had commenced employment prior to a new Criminal Records Bureau (CRB) being received or Protection of Vulnerable Adults (POVA) checks being undertaken. The manager must ensure that a CRB check is applied for and POVA checks have been undertaken, prior to staff commencing work. Staff can then undertake work under the Care Home Regulations 7,8,9,10 and 11. This is Requirement 10. Staff files show that staff have undertaken training in areas such as fire safety, moving and handling, pressure area care, administration of medication and awareness of Huntingdon’s Chorea, Parkinson’s disease and diabetes. However, some of this training is not recent, only four of the care staff have achieved their NVQ2 and some of the staff have not undergone formal training in Adult Protection/Abuse Awareness. The registered persons must ensure that the care staff have the necessary skills and training to meet the individual needs of the residents and to ensure their safety. This is Requirement 11. Avondale Nursing Home DS0000025947.V272638.R01.S.doc Version 5.0 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, 36, and 38 Standard 35 was not tested on this visit. However the judgement from the last inspection was that residents’ financial interests were safeguarded. The home is managed in a way that meets the health and personal care needs of the residents, but the registered persons need to pay more attention to some aspects of the home, such as, the care plans, risk assessments and health and safety. All of these aspects affect the quality of life of the residents. The registered persons do not have adequate systems in place to ensure that the service users are supported by staff who are appropriately supervised. EVIDENCE: Standard 35 was not specifically tested on this visit, as there were no outstanding requirements in relation to this standard, which were assessed at Avondale Nursing Home DS0000025947.V272638.R01.S.doc Version 5.0 Page 21 the last inspection as met. This standard will be re-tested at a future inspection. During the last inspection it was noted that residents’ care plans were left on a table in one of the lounges. This meant they were not being securely stored and anyone walking through the lounge could have seen them. The managers had purchased a lockable trolley and this was to be used with immediate effect. No requirement was set but during this inspection it was noted that all care plans were being stored in a lockable trolley, which keeps residents’ personal records secure. Some of the policies and procedures that were examined during the last inspection were not dated or signed, therefore it was not possible to confirm what status they had. These documents were examined during this inspection and these have now been signed and dated. This requirement is now met. During the last inspection the lift was out of order and though the managers had taken appropriate steps to ensure the well-being of the residents, they had not undertaken any formal risk assessments regarding the residents and staff. This should have included residents having to use the stairs as opposed to the lift. There was evidence at this inspection that these risk assessments had been completed. This requirement is now met. There is not a system in place for the regular monitoring and auditing of the care plans nor the reviewing of risk assessments. Staff are not supervised on a regular basis and their training needs are not audited. The registered must have adequate systems in place to ensure that the staff are able to meet the needs of the residents. This is Requirement 12. The home has recently commenced residents’ and relative’s meetings which have been well received. However the managers need to look at undertaking user satisfaction questionnaires, as well as relatives and stakeholders quality assurance surveys. The results then need to be built into an annual development plan for the home. This is Requirement 13. Staff files were examined and there was no evidence that either nursing or care staff receive regular formal supervision. Neither was there evidence that yearly appraisals are taking place, this is where staff’s development and training needs would be identified. This is Requirement 14. A requirement was set at the previous two inspections that regular checks are made on all hot water outlets. This was in order to ensure that safe water temperatures are always maintained. The record was again checked on this visit, and it was noted that this only covered residents’ bedrooms, but not the kitchen, bathroom, staff facilities or communal toilets. This requirement has therefore been brought forward as Requirement 15 with a new timescale. This is the second time that this requirement has been brought forward and the Avondale Nursing Home DS0000025947.V272638.R01.S.doc Version 5.0 Page 22 owners/managers need to be mindful that non-compliance could result in the Commission taking enforcement action to ensure the safety of service users and staff. Avondale Nursing Home DS0000025947.V272638.R01.S.doc Version 5.0 Page 23 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 x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 2 3 3 3 3 3 3 x 3 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 x x 2 x 2 Avondale Nursing Home DS0000025947.V272638.R01.S.doc Version 5.0 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15(2) Requirement The registered persons must ensure that all needs, including changing needs are accurately recorded in each individual care plan. The daily recording system must be accurate and show how both nursing and care staff met these needs. Previous timescale of 31/08/05 not met The registered persons must ensure that all risk assessments are completed and reviewed at least monthly The registered persons must keep the resident’s plan under review. The registered persons must ensure that the residents’ social and recreational interests and needs are identified and met. A record of activities must be kept, which clearly shows each resident’s involvement in each activity. Previous timescale of 30/09/05 not met. The registered persons must ensure that the menus accurately record the food that is being served. DS0000025947.V272638.R01.S.doc Timescale for action 30/04/06 2 OP8 13 (4) 30/04/06 3 4 OP7 OP12 15(2) (b) 16(2)(n) 30/04/06 31/05/06 5 OP15 16 28/02/06 Avondale Nursing Home Version 5.0 Page 25 6 OP16 22 7 OP16 37 8 9 OP18 OP29 13 (6) 19 10 OP29 19 11 OP30 18 (1) 12 OP31 10 13 OP33 24 14 OP36 18 (2) The registered persons must maintain a detailed record of all complaints. This must include complaints or concerns, even where they are resolved at an early stage. Previous timescale of 30/10/05 not met The registered persons must ensure that they inform the Commission without delay of all events that fall within the remit of Regulation 37.Previous timescale of 30/07/05 not met. All staff must receive formal training in Adult Protection/Abuse Awareness. The registered persons must receive two written satisfactory references prior to a member of staff commencing work at the home. A criminal Records Bureau check must be requested for new staff prior to them commencing work in the home. The registered persons must ensure that all care staff receive training appropriate to their work, and suitable assistance given for care staff to obtain further qualifications. The registered providers must ensure that they have adequate systems in to ensure the safety and well being of the residents. The registered persons must ensure that a quality assurance must be in place. This system must seek the views of residents, relatives and stakeholders. A copy of this report must then be forwarded to the Commission and made available to all interested parties. The registered persons must ensure that all staff are appropriately supervised at least six times a year. DS0000025947.V272638.R01.S.doc 30/06/06 28/02/06 31/07/06 01/02/06 01/02/06 30/09/06 30/06/06 31/08/06 30/06/06 Avondale Nursing Home Version 5.0 Page 26 15 OP38 23 (2) To ensure that safe water temperatures are being maintained. The registered persons must ensure that regular checks are undertaken and temperatures recorded. Previous timescales of 30/11/04 and 30/07/05 not met 31/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Avondale Nursing Home DS0000025947.V272638.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU 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. 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