Inspection on 22/06/05 for Avondale Nursing Home

This inspection was carried out on 22nd June 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 Nursing Home 11/09/07

Avondale Nursing Home 06/07/06

Avondale Nursing Home 19/01/06

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 0BS Lead Inspector Edi OFarrell Unannounced Inspection 22 June 2005 10:35 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 Nursing Home G55_S0000025947_Avondale_V234310_220605_Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Avondale Nursing Home Address 26 Snakes Lane West, Woodford Green, Essex IG8 0BS 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) 020 8506 2194 020 8559 0251 Mrs Inderjeet Kaur Ford Ms Elizabeth Ruth Polkinhorn Ms Elizabeth Ruth Polkinhorn CRH Care Home 20 Category(ies) of OP Old age (20) registration, with number of places Avondale Nursing Home G55_S0000025947_Avondale_V234310_220605_Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 16 November 2004 Avondale Nursing Home G55_S0000025947_Avondale_V234310_220605_Stage 4.doc Version 1.30 Page 5 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 accomodation is comprised of a two storey detached house with purpose built extentions to the side and rear. There is car parking 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 bedrooms. The remaining bedrooms are on the upper floor, along with bathrooms and toilets. There is a lift to the second floor, though this was not working on the day of the inspection. There are two double bedrooms, both of which have an ensuite toilet, and 16 single rooms, many of which also have an ensuite toilet. The home is privately owned by two business partners who are jointly registered as the manager. They employ a matron to oversee the day-to-day care of the service users. Avondale Nursing Home G55_S0000025947_Avondale_V234310_220605_Stage 4.doc Version 1.30 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This, unannounced, inspection took place on a weekday from mid morning to mid afternoon. The building was toured, including bedrooms, and all 16 current service users were spoken to. Care plans were examined, along with other records, such as accident reports, the staff rota, and menus. Issues arising from this were then discussed with staff members or with the owners/registered managers and the matron. Ten Requirements and one Recommendation set at the previous inspection were followed up in order to see what action had been taken. The new format of the report, with the emphasis on outcomes for service users, was explained to the managers, and leaflets about the Commission were left for the staff to give to relatives. What the service does well: What has improved since the last inspection? Some building work has been done so that one of the three double bedrooms has now been split into two single rooms, both with ensuite toilets. In addition some bedrooms have been redecorated and had new carpets fitted. The remainder are due to be done over the next few weeks. In order to minimise disruption the number of people living in the home has been reduced whilst this work has been going on. Avondale Nursing Home G55_S0000025947_Avondale_V234310_220605_Stage 4.doc Version 1.30 Page 7 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 G55_S0000025947_Avondale_V234310_220605_Stage 4.doc Version 1.30 Page 8 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 Nursing Home G55_S0000025947_Avondale_V234310_220605_Stage 4.doc Version 1.30 Page 9 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, 3, 4 & 5 Representatives of prospective service users have the information they need to make informed choices about admission, and have an opportunity to visit the home and assess the quality of care. Service users have their needs assessed prior to moving into the home and at the stage of admission, and they, and their representatives, know that the home can meet their needs. EVIDENCE: Five care plans were examined, including those of two recent admissions, and the assessments were discussed with a member of staff or management. The five service users were spoken to, and staff were observed providing care to them. There is a Statement of Purpose and a Service User Guide, both of which will need a minor amendment now there are two, rather than three, double rooms. This is Requirement 1. Avondale Nursing Home G55_S0000025947_Avondale_V234310_220605_Stage 4.doc Version 1.30 Page 10 Service users can visit the home prior to a decision being made about admission, but it is more usually a relative who does so. Once admitted there is a four-week trial period, followed by a review meeting, to allow all parties to make a decision about the ability of the home to meet the needs of the service user. One of the service users had been admitted during the weekend preceding the visit as an emergency at the request of her relatives. As this person is self-funding there is no community care assessment by the Local Authority, and as an emergency no pre-admission assessment by the home. The relative had previously visited the home, and stated that once a place became available they wished for the service user to move in. The Matron stated that once the redecoration of bedrooms was completed then a preadmission assessment would have been carried out, but that the events leading up to the service user being admitted precluded this. The information seen in the care plans supported this, and a nurse, on admission, had carried out a full assessment. This identified both nursing and personal care needs, including immediate treatment needs regarding tissue viability. Arrangements had been made for this service user to be fully checked out by a Doctor. The managers have restricted new admissions whilst the building and redecoration work has been carried out, in order to make sure that all needs can be met, with the least disruption to the lives of the current residents. Avondale Nursing Home G55_S0000025947_Avondale_V234310_220605_Stage 4.doc Version 1.30 Page 11 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 in part & 10 Service users’ health and personal care needs are set out in individual plans of care, but inconsistencies and omissions in recording of the care to be, and being, provided could mean that they are not fully met. The home is not fully following their medication administration policy and procedure. Service users feel they are treated with respect and their right to privacy is upheld but this may not always be the case. EVIDENCE: Five care plans were examined, and cross-referenced with other records such as the accident book and medication administration (MAR) charts. In addition service users were asked for their views, and staff were observed carrying out their duties. The home has a good assessment, care planning, and recording system in place for the provision of nursing and personal care. Needs are set out and Avondale Nursing Home G55_S0000025947_Avondale_V234310_220605_Stage 4.doc Version 1.30 Page 12 how these are being met by both nursing and care staff should be recorded in the daily log which is a part of the care plan documentation. Recent accident reports had corresponding entries in the daily log, and changes to the care plans, thus ensuring that staff would know about changing needs and how to meet them. The care plans have a sheet for visiting professionals to complete and in one case the Tissue Viability Nurse (TVN) had recently visited and left advice as to appropriate treatment for a wound. This had not been transferred to the log or to the care plan. This was discussed with the matron and the managers, who reported that this type of information would be noted in a separate communication book. This book was examined along with the MAR chart in order to see if there was any evidence that the advice had been followed. There was no record in either of the change of treatment. One of the managers, who is a qualified first level nurse, confirmed that she had changed the dressing two days before the inspection and had followed the advice given by the TVN. She and the matron also confirmed that the GP had been requested to provide a prescription for the new treatment, and in the meantime, as the home had both the external application and dressing that the TVN had advised, these had been used. The service user stated that the wound was not causing her any distress, and that it was being dressed on a regular basis. Whilst the Commission is prepared to accept the word of the manager that the service user is being given the appropriate treatment for her wound we are concerned that accurate records are not being maintained, as this could lead to the advice of the TVN being missed by nursing staff. This is Requirement 2. A Requirement was set at the previous inspection that a risk assessment must be carried out for a service user who self-medicated at lunch time. This service user is no longer living in the home, but a policy on self-medication has been drafted. This was examined and discussed with the matron and managers. Some omissions were noted, such as the storage of medication in a service user’s bedroom. Whilst the Commission accepts the view of the managers of the home that this would not be usual practice, due to the level of disability of the service users, a comprehensive self-medication policy and risk assessment procedure must be in place. This is Requirement 3. Service users spoken to who could express their views were clear that staff treated them well, including with respect and dignity. Staff were observed indirectly during the visit and, in the main, were seen to carry out their duties using a person centred approach. There were two issues where the inspector observed that service users’ privacy and dignity were compromised. These were discussed with the managers and matron that have lead to Requirement 4. A Requirement was set at the previous inspection that there be a system in the home for the appropriate labelling of service users’ personal clothing. This was because whilst some items of clothing had labels, in others the service user’s name had been marked directly onto the item. On the initial tour of the Avondale Nursing Home G55_S0000025947_Avondale_V234310_220605_Stage 4.doc Version 1.30 Page 13 building during this visit several items of clothing were seen in the dry laundry basket to still have the latter type of marking. This was discussed with the managers, who reported that one member of staff has taken responsibility for ensuring that all clothing is labelled in such a way as to maintain the dignity of service users. They reported that the items seen may have been those of residents who had been in the home prior to the last inspection, and as this was not checked out further Requirement 5 has been taken forward from the previous inspection with a new timescale. Avondale Nursing Home G55_S0000025947_Avondale_V234310_220605_Stage 4.doc Version 1.30 Page 14 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 & 15 Service users’ social and recreational needs and wishes are identified in care plans, but there are no records to demonstrate that the home gives a high priority to this important area of the care of older people. The home does hold some social and recreational events, but does not record these, or who takes part in each activity. The home offers a varied menu, and is currently in the process of reviewing this, in order to increase the amount of fresh ingredient of all meals. EVIDENCE: Care plans were examined and service users were asked for their views, and this aspect of care was discussed with the managers. Two Requirements were set at the previous inspection relating to these Standards; firstly that either staffing levels must be increased to allow for more activities, or an activities co-ordinator be employed; secondly that service users’ interests be recorded, and attempts be made to meet these. On the afternoon of the visit a regular singing event was taking place, which some of the service users were obviously enjoying. The managers reported that other regular activities were music and movement, bingo and quizzes, but Avondale Nursing Home G55_S0000025947_Avondale_V234310_220605_Stage 4.doc Version 1.30 Page 15 that no action has been taken in relation to the Requirement to either increase staff or employ an activities co-ordinator. Although the managers and matron reported that activities do take place there was no record in the daily logs seen, so it was not possible to judge, apart from observation during the visit, how service users spend their days. Service users’ interests were recorded in the five care plans that were examined, and some service users said that they were happy with the level of activity. As this issue was raised by both service users and relatives at the last inspection the two Requirements set then have been taken forward as a new Requirement 6, so that the home and the Commission will continue to review this important aspect of the care of older people. The visitors’ book demonstrated that relatives and friends feel free to visit at any time, and the `Thank You’ cards on the notice board made particular reference to how welcome relatives and friends had been made when they visited. Preferred times of going to bed and getting up, and term of address were noted in each care plan seen, as were likes and dislikes in relation to food and drink. During the visit there were several times when staff responded promptly to service users’ requests for a change of routine. The current menu was examined, and discussed briefly with the cook, and the serving and delivery of the midday meal was observed. A new cook has recently started at the home and is in the process of revamping the menu, as she feels that it has been too reliant on processed foods. Until the new menu is in place she is keeping a record of all food offered, and the temperature that it is served at, and this was examined. A Requirement was set at the previous inspection in relation to pureed meals needing to be offered more attractively. Management of the home have responded to this by purchasing some new plates, which separate out different types of food, thereby making the presentation more appealing to the service users. Avondale Nursing Home G55_S0000025947_Avondale_V234310_220605_Stage 4.doc Version 1.30 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 & 18 in part There is no evidence to suggest that these Standards are not met, but the home has not been reporting all incidents to the Commission, due to a lack of awareness of the Regulations. EVIDENCE: The log of complaints was examined, but as there were no complaints logged since August 2004 it was not possible to fully judge the home’s current performance against this set of Standards. Some service users were clear as to what they would do if they had a complaint, but, due to the level of disability, others could not give a view. The low level of complaints may be because the owners/managers are at the home on a very regular basis, and therefore deal with concerns at a very early stage, and therefore do not perceive them as complaints. It was noticeable that the complaints that were in the log corresponded to complaints that the Commission had been involved in, i.e. by direct contact. During the visit one service user complained about the behaviour of another service user the previous night i.e. she said that he kept her awake. The matron was able to provide a reasonable explanation in response to this, but had not logged it as a complaint. Requirement 7 has been set so that the managers prioritise time over the coming months to concentrate on this aspect of care. Staff have had training in the protection of vulnerable adults, and the home has a policy and procedure. Of concern to the Commission is that neither the managers nor the matron appeared to know about Regulation 37 notifications, apart from death. Regulation 37 requires all Registered Persons to notify the Avondale Nursing Home G55_S0000025947_Avondale_V234310_220605_Stage 4.doc Version 1.30 Page 17 Commission about significant events in the home that may adversely affect the well-being or safety of any service user. The records held by the Commission show that this Regulation has been complied with where there has been a death of a resident, but checks against the records held in the home, and discussions with the managers highlighted that other significant events have not been reported, i.e. serious falls, and visits to accident and emergency at the local hospital. The need to inform the Commission of such events was discussed with the matron early during the visit, as the lift had broken down the previous evening resulting in an emergency plan having to be put in action. The home, including the managers/owners, had responded promptly and appropriately to this emergency, working effectively so as to cause as little disruption to the service users as possible. At the start of this visit the matron was asked to phone the duty officer at the Commission to report this incident, and to complete a Regulation 37 form. Later during the visit this aspect of care was discussed with the owners/manager and the matron, and advice given as to future reporting. Requirement 8 covers this point, as the reporting of incidents is an important monitoring tool for both the on-site management of homes and the Commission. Avondale Nursing Home G55_S0000025947_Avondale_V234310_220605_Stage 4.doc Version 1.30 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 22, 23, 24, 25 & 26 only as they currently impact on the immediate health, safety and welfare of the service users and staff. This set of Standards could not be fully judged due to the current programme of redecoration, but the Commission is satisfied that service users are living, and staff are working, in a safe environment whilst the work is on-going. EVIDENCE: All of the Standards in this section have been scored as not assessed, as due to the redecoration work it was not possible to judge if the environment of the home would fully meets the needs of 20 service users. Due to rooms being painted and new carpets being fitted several pieces of equipment were seen to be stored in inappropriate places, such as bathrooms, but as these did not pose any hazard to service users no Requirements have been set. Some minor defects were brought to the attention of the managers during the inspection, and they immediately got the handyman to deal with them, so again no Requirements have been set. Avondale Nursing Home G55_S0000025947_Avondale_V234310_220605_Stage 4.doc Version 1.30 Page 19 The passenger lift between the ground and first floor had broken down during the evening prior to the inspection. The managers had responded to this promptly, and had put in place an emergency plan so that the lives of service users were disrupted as little as possible. There was however no written risk assessments in place, nor had the Commission been informed of this event. During the tour of the building it was apparent that two service users, who would normally be downstairs, had to spend the day in their bedroom. Two other service users had had to sleep downstairs the previous night, one in an empty bedroom, and another on a mattress in the lounge. By the end of the visit the managers had been informed by the lift maintenance company that it would be repaired by the end of the week. The matron and the inspector jointly completed a Regulation 37 notification, and the managers were requested to inform the Commission once the work was completed, or if there were any delays in the lift becoming fully operational. The Commission contacted the home two days following the visit and the matron confirmed that the lift had been repaired and was in full working order. During the visit the home was seen to be clean and free from any offensive odours, Avondale Nursing Home G55_S0000025947_Avondale_V234310_220605_Stage 4.doc Version 1.30 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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 Service users’ health and personal care needs are met by the numbers and skill mix of staff, but the lack of records of activities means that it is not possible to judge if social and recreational needs are also met. EVIDENCE: The staff rota was examined and the numbers on duty during each shift was compared with the observed needs of service users, and the care plans. There was evidence that the existing staffing levels meet the health and personal care needs. There was also evidence of extra staff being brought in to deal with the effects of the lift breaking down. As identified at the previous inspection the staffing levels do not appear to allow for social or recreational activity. Requirement 6 also relates to this set of Standards. Avondale Nursing Home G55_S0000025947_Avondale_V234310_220605_Stage 4.doc Version 1.30 Page 21 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) 31, 35, 37 & 38 The home is managed in a way that meets basic health and personal care needs of residents, but the managers/proprietors need to pay more attention to some aspects. These are policies and procedures, risk assessment, and health and safety. All these aspects affect the quality of life of the service users. EVIDENCE: At the last inspection a Requirement was set that the duty rota must record the hours that each registered proprietor/manager works. This was in order to ensure that it is always clear who is responsible for the home at all times. This was discussed with the matron and managers during this visit, and the most appropriate way for this to be achieved was agreed. The Requirement has therefore not been taken forward, but will be checked on again at the next inspection, as it is important for service users, their relatives and staff to know who has ultimate control of the home at all times. Avondale Nursing Home G55_S0000025947_Avondale_V234310_220605_Stage 4.doc Version 1.30 Page 22 A Requirement was set at the previous inspection that the system used by the home to handle and record service users’ money be reviewed. Two sets of accounts were checked during this visit, and both were in order, with the written records matching the amounts held. During the inspection it was noted that the service users’ care plans were left on a table in one of the lounges. This means that they were not being stored securely in that anyone walking through the room could have looked at them. The matron and managers had already identified that this is unacceptable and have purchased a lockable trolley for the purchase of storing the care plans. As the managers reported that this was to be used immediately no Requirement has been set, but this will be checked again at the next inspection. Some of the policies and procedures that were examined were not dated and signed; it was therefore not possible to confirm what status they had. This is important because staff in their daily work should use these sorts of documents, to make sure that they are following correct procedure. They need to know that the document they are using has been agreed by management, and is up-to-date. This is Requirement 9. Because the lift was out of order the main concentration during the visit in relation to health and safety was on how this adverse event was being managed. As stated earlier in this report this had happened the previous evening, which was a Tuesday. The Commission was later informed that the lift was in working order on the Friday afternoon. This event affected both the daily life of service users, and the working practices of staff, and therefore risk assessment should have immediately been carried out, alongside the implementation of emergency plans. The managers and staff acted promptly in attempting to contact the lift maintenance firm, and in identifying which service users would be affected. They then made alternative sleeping arrangements for two service users, and brought in extra staff to cover this. They also identified which service users would be affected by the lift being out of order for the next day and made suitable arrangements. They did not, however, carry out any formal risk assessments for either service users or staff. This should have included assessing the risk to both groups by service users having to use the stairs as opposed to the lift. This omission was discussed with the matron and a format for immediate assessment was agreed. This is Requirement 10. A Requirement was set at the previous inspection 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 checked on this visit, and it was noted that this only covered service users’ bedrooms, but not the kitchen, bathrooms, staff facilities, or communal toilets. The Requirement has Avondale Nursing Home G55_S0000025947_Avondale_V234310_220605_Stage 4.doc Version 1.30 Page 23 therefore been brought forward in this report as Requirement 11 with a new timescale. Avondale Nursing Home G55_S0000025947_Avondale_V234310_220605_Stage 4.doc Version 1.30 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION x x x x x x x x STAFFING Standard No Score 27 2 28 x 29 x 30 x 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 3 x 2 2 Avondale Nursing Home G55_S0000025947_Avondale_V234310_220605_Stage 4.doc Version 1.30 Page 25 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 1 Regulation 4&5 Requirement Timescale for action 31/08/05 2. 7&8 12 & 15 3. 9 13 (2) 4. 10 12 (4) (a) The Registered Persons must amend the Statement of Purpose and the Service Users Guide so that both documents reflect the reduction in the number of double rooms. 31/08/05 The Registered Persons must ensure that all needs, including changing needs, are accurately recorded in each individuals care plan. This must include how the need is to be met, including specific treatment. The daily recording system must be accurate and show how both nursing and care staff have met these needs. The Registered Persons must 30/09/05 ensure that there is a comprehensive policy and procedure in place for thoses service users who may be able, and wish, to self-medicate. This must include how medication retained by service users will be stored. The Registered Persons must 31/08/05 ensure that all staff always respect the privacy and dignaty of all service users. Version 1.30 Avondale Nursing Home G55_S0000025947_Avondale_V234310_220605_Stage 4.doc Page 26 5. 10 12 (4) (a) 6. 12 & 27 16 (m) & (n) 7. 16 & 18 13 (6) & 22 8. 16 & 18 37 9. 37 17 10. 38 23 It is a requirement that there is a system in the home for the appropriate labelling of service users personal clothing. Previous timescale of 31/01/05 not met. The Registered Persons must ensure that the service users social and recreational interests and needs are identified and met, as far as is possible. A record of activities must be kept, which clearly shows each service users involvement in each activity. The Registered Persons must maintain a detailed record of all concerns and complaints raised about the service provided by the home. This must include complaints or concerns raised by service users or residents, even where they are resolved at an early stage A summary report must be provided to the Commission outlining the number of complaints/concerns raised, how these have been investigated, and the outcomes for the complainant. The Registered Persons must ensure that they inform the Commission without delay of all occurances which fall within the remit of Regulation 37. Where such information is provided orally it must be confirmed in writing. All documents, such as policies and procedures, that are required for the smooth running of the home must be dated and signed by an appropriate person. This is so that staff following the procedures are clear that they are authorised and up-to-date. The Registered Persons must Version 1.30 31/08/05 30/09/05 30/10/05 30/07/05 31/08/05 22/06/05 Page 27 Avondale Nursing Home G55_S0000025947_Avondale_V234310_220605_Stage 4.doc 11. 38 & 25 12 (1) (a), 13 (4) & 23 ensure that full risk assessments are carried out when events occur, which result in the lifestyle of service users having to change, or the working patterns of staff to change. The Registered Persons must ensure that regular checks are undertaken and recorded on all hot water outlets to ensure safe water temperatures are being maintained. Previous timescale of 30/11/04 not met. 30/07/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Avondale Nursing Home G55_S0000025947_Avondale_V234310_220605_Stage 4.doc Version 1.30 Page 28 Commission for Social Care Inspection Ferguson House 113 Cranbrook Road Ilford Essex 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. Extracts may not be used or reproduced without the express permission of CSCI Avondale Nursing Home G55_S0000025947_Avondale_V234310_220605_Stage 4.doc Version 1.30 Page 29 - 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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