CARE HOME ADULTS 18-65
Avondale Nursing Home Delphside Ltd 11 Sandstone Drive, Off Delph Lane Whiston Prescot Merseyside L35 7LS Lead Inspector
Miss Diane Sharrock Miss Lorraine Farrar Unannounced Inspection 27th June 2006 11:45 Avondale Nursing Home DS0000005451.V295252.R01.S.doc Version 5.2 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 DS0000005451.V295252.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 Adults 18-65. 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 DS0000005451.V295252.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Avondale Nursing Home Address 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) Delphside Ltd 11 Sandstone Drive, Off Delph Lane Whiston Prescot Merseyside L35 7LS 0151 431 0330 0151 430 0186 Delphside Limited Mr Peter Hamlett Care Home 50 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (50) of places Avondale Nursing Home DS0000005451.V295252.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Service Users to Include up to 50 (MD) Date of last inspection Brief Description of the Service: Avondale Nursing Home is a purpose built unit providing 24 hour nursing care for residents with mental health problems. The home is run by a charity, Delphside, which was formed in 1991. The home accommodates up to 50 residents at one time. The organisation recognises that on admission to the home residents may be very ill, however symptoms may subside over a period of time. As the home has provided a long stay placement for many for a lot of the Residents it now has approximately 16 Residents who are over 65 years. The Manager is applying for a variation to the present registration to ensure all age ranges are included in the homes registration certificate. The home is located in the Prescot area of Liverpool, close to Whiston Hospital and is easily accessible by road and public transport. It is on ground floor level and split into four separate units. There is also a substantial garden area surrounding the home. Avondale Nursing Home DS0000005451.V295252.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection took place over one day with two Inspectors present and was the homes key unannounced inspection measuring all of the core standards. A detailed tour of the premises took place and Resident care plans and various other records were inspected. A selection of comment cards were sent to a sample of named Residents and further comment cards have been left at the home. Interviews took place with both Staff and Service Users. In total 2 Resident comment cards have been submitted to CSCI and 1 care manager comment form. All areas of the inspection and findings were discussed with the Manager and his senior management team at the end of this visit with written feedback also provided. What the service does well: What has improved since the last inspection?
Avondale Nursing Home DS0000005451.V295252.R01.S.doc Version 5.2 Page 6 There have been various initiatives from the company including, audits and training to improve on the administration and storage of medications. This has led to Staff now offering a more individualised approach to assisting Residents with their medications. Medications are no longer administered from the storage area were Residents previously queued up and staff now take medicines to Residents own rooms or lounge/living area. The company have plans and support in place for those persons who want help in smoking cessation. Some positive interactions were observed between Residents and Staff. What they could do better:
Full feedback was given to the Manager during and on conclusion of this inspection. There were various improvements noted especially in evidencing that outstanding regulations were now being met. However other areas were noted to need action taken and further evidence to be in place to meet most other standards. 1) Medicines are much improved. Further developments to the daily recording of the fridge temperatures need to be consistently in place. Medication records need further work to enable staff to record and sign for any specific changes to the prescribed instruction for medications. Although previous audits had taken place it was acknowledged that they must be carried out on a regular and consistent basis to ensure that appropriate standards are always in place. 2) Further developments to the environment should take place especially in developing younger adult facilities. Staff should continue their role in developing the model to incorporate ideas to promote a more “homely” atmosphere and a less institutional approach eg to remove staff official notices from residents areas, to develop and refurbish bathrooms and hallways incorporating younger adults opinions. 3) The care plans seen were mostly evidenced as meeting the standards however some areas need further development. There is a lot of good detail for clinical input but some care plans are basic and could benefit from external sources of information eg the scott clinic assessments. Care plans should incorporate more information covering personal care needs, social support and rehabilitation and models of support. Pen pictures could be developed further as well as admission assessments. 4) Fire records were mostly noted to be detailed however regular in house recorded checks must be in place for fire extinguishers and emergency lighting.
Avondale Nursing Home DS0000005451.V295252.R01.S.doc Version 5.2 Page 7 5) Finance records were found to be very detailed however a company review must take place to ensure that each Residents personal allowance is transferred into their account held at the home once paid to the company appointee ship. Presently personal allowances are not transferred over until 4 weeks after they have been paid by the DHSS authorities. The company must review the process of how or if Residents are given any interest generated from the currently managed account. 6) Staff supervision must be developed to meet the national minimum standards as currently they are not meeting this standard. 7) Training and developments plans for the home must be reviewed so that actions can be planned to ensure staff targets for having NVQ qualifications are in place. 8) A company policy should be developed for Equality and diversity issues so that staff have clear guidance and support in meeting all Residents needs. 9) Staff personnel files were noted to be generally improved, however just one issue recognised that some files did not keep evidence of staff identification. A company review should be carried out to ensure all personnel files are kept in accordance to the care home regulations 2001. 10) The presentation of food should be reviewed especially for liquidised food as it was acknowledged that sometimes the food is blended together. 11) Some issues were identified by various Residents who agreed for their points to be put forward to the Manager to be addressed. These points coveredSome felt the Television was turned off at a certain time. Some Residents felt they were told to put their nightclothes on. One Resident felt they had seen cockroaches. One Resident stated their mattress was hard and this was evidenced by the inspector. Their bedroom door lock was broken and they did not have a chair in their bedroom. One staff member was observed walking into a Residents bedroom without knocking on their door first. This practice must be reviewed by the manager including the use of inappropriate language ie in how some people talk to Residents and their approach to various conversations. 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 DS0000005451.V295252.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Avondale Nursing Home DS0000005451.V295252.R01.S.doc Version 5.2 Page 9 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Potential residents can make an informed choice before moving into the home. Quality in this outcome Area is, Good, this judgment has been made using available evidence including a site visit to the service EVIDENCE: Residents who are thinking of moving into the home are visited by the manager who completes an assessment. The resident is given a copy of the homes statement of purpose and service user guide which details what the home offers. This allows them to make an informed choice. Residents move into the home on an initial three month trial period to allow staff and the resident themselves time to see if the home is suitable. One pre assessment gave brief details about a residents previous mental health problems, this record was note dated, but it did another care record gave details regarding their thoughts about their illness, details of their behaviour, mood, speech and physical health problems. This is then used along side the ‘clinical risk assessment tool’ which looks at risks that are presented to the resident, other people and the environment. Both of these documents are then used by staff to make a detailed plan of care for residents. Avondale Nursing Home DS0000005451.V295252.R01.S.doc Version 5.2 Page 10 Avondale Nursing Home DS0000005451.V295252.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6/7/9 There continues to be progress made in the care records.. Quality in this outcome area is adequate. This judgment has been made using available evidence including a site visit to the service. EVIDENCE: Some care plans were case tracked and some had plans of care available. The company have developed all care records. The company have taken a lot of effort to develop the care records so that they will be clear in how they meet individual needs and in meeting the national minimum standards. The care plans seen were mostly evidenced as meeting the standards however some areas need further development. There is a lot of good detail for clinical input but some care plans are basic and could benefit from external sources of information eg the scott clinic assessments. Care plans should incorporate more information covering personal care needs, social support and rehabilitation and models of support. Pen pictures could be developed further as well as admission assessments. Avondale Nursing Home DS0000005451.V295252.R01.S.doc Version 5.2 Page 12 Some issues were identified by various Residents who agreed for their points to be put forward to the Manager to be addressed which coveredSome Residents felt the Television was turned off at a certain time. Some Residents felt they were told to put their nightclothes on. One Resident stated their mattress was hard and this was evidenced by the inspector. Their bedroom door lock was broken and they did not have a chair in their bedroom. One staff member was observed walking into a Residents bedroom without knocking on their door first. All of these points must be reviewed by the manager with appropriate feedback given to Residents regarding their comments and opinions so that appropriate support can be demonstrated in supporting all Residents in making choices. The manager agreed at the close of this inspector to investigate all comments and would take appropriate action following this inspection. Residents living at the home are invited to attend the residents forum, Residents use this forum to give ideas and suggestions as to the running of the home, activities and trips out. Avondale Nursing Home DS0000005451.V295252.R01.S.doc Version 5.2 Page 13 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12/13/15/16/17 Individual activities are implemented. Family members are kept informed and involved with regular contact. Quality in this outcome area is good. This judgment has been made using available evidence including a site visit to the service. EVIDENCE: Residents and staff confirmed that the home allows visitors at any time of the day. The home have a structured activity plan which is displayed throughout the home and discussed as part of the residents forum. Activities take place both inside and outside the home and are supported by staff with regular residents forums taking place also. There were various positive comments from Residents and Staff who were all very enthusiastic. Most interactions between Staff and Residents were observed as being very good and offering a good rapport however, one staff member was observed walking into a Residents bedroom without knocking on their door first. This practice must be reviewed by the manager including the use of inappropriate Avondale Nursing Home DS0000005451.V295252.R01.S.doc Version 5.2 Page 14 language ie in how some people talk to Residents and their approach to various conversations. Residents and staff confirmed that the home allows visitors at any time of the day. The current presentation of liquidised food should be reviewed to ensure an improved presentation to blended food eg maybe implement the use of moulds for food products so they visually look like the food that has been blended, ie a pork chop mould. Avondale Nursing Home DS0000005451.V295252.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18/19/20 Care plans are being developed and should include how Residents receive personal care in the way they prefer maximising choice and independence Specialist health care support is offered to residents and ensures that health needs are met. The administration of medication needs continued reviews taking place to ensure consistent good practice.. Quality in this outcome area is adequate. This judgment has been made using available evidence including a site visit to the service. EVIDENCE: The development of care plans should include more detail around the choices of Residents including the support needed and offered for personal care. Generally comments were very positive which was also stated in one Resident comment card and another care managers comment card. However some Residents have made comments specifically about choices being impinged on especially at night while watching television. Appropriate action must be taken to ensure that all Residents are supported in their choices and rights eg to go to bed when they choose and change in to their nightwear when they want to. Residents were observed to be accessing various areas of the home independently of staff. Residents were also observed using their rooms and areas outside of the home independently.
Avondale Nursing Home DS0000005451.V295252.R01.S.doc Version 5.2 Page 16 Staff discussed the training opportunities that they had been given regarding medication practices since the last inspection. Feedback was positive and Staff felt they had developed the administration of medications with the priority being to give the Residents a more personalised approach. Medications are no longer administered from the storage area were Residents previously queued up and staff now take medicines to Residents own rooms or lounge/living area. Staff acknowledged how this had been a beneficial change and described how they are hoping to look at other initiatives to benefit the Residents. The administration and management of medicines are much improved. Further developments to the daily recording of the fridge temperatures need to be consistently in place. Medication records need further work to enable staff to record and sign for any specific changes to the prescribed instruction for medications. Although previous audits had taken place it was acknowledged that they must be carried out on a regular and consistent basis to ensure that appropriate standards are always in place. Avondale Nursing Home DS0000005451.V295252.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22/23 The management state there are no complaints. However various comments were shared with Inspectors. Mandatory training for staff needs to be up to date to ensure all staff are trained in the protection of vulnerable adults. The management of Guests finances is well managed however the transfer of personal allowances should be reviewed. Quality in this outcome area is adequate. This judgment has been made using available evidence including a site visit to the service. EVIDENCE: The home have a complaints procedure that is accessible around the home for Residents. Residents have their views listened to by staff and also via the forums. Although here are processes such as the forums to enable Residents to give opinions it should be acknowledged that some Residents made various comments that possibly effected there day to day lives and the recording of such comments and actions taken may help in reviewing these opinions whether the company identify them as formal complaints or informal complaints they still need the necessary action and input from senior management. This may help in reviewing any type of audit of both formal and informal complaints. One comment card received later after the inspection raised various complaints which will be directed to the manager to review and investigate. The management and investigation of complaints needs a review to ensure all complaints and opinions are acted upon and possibly look at other ways for Residents to air their views eg anonymous processes, regular questionnaires. Finance records were found to be very detailed however a company review must take place to ensure that each Residents personal allowance is transferred into their account held at the home once paid to the company
Avondale Nursing Home DS0000005451.V295252.R01.S.doc Version 5.2 Page 18 appointee ship. Presently personal allowances are not transferred over until 4 weeks after they have been paid by the DHSS authorities. The company must review the process of how or if Residents are given any interest generated from the currently managed account. Staff have been receiving training on ‘abuse awareness’ and felt they were up to date with all mandatory training. Avondale Nursing Home DS0000005451.V295252.R01.S.doc Version 5.2 Page 19 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24/30 The home was clean and tidy but needs further development to promote a more homely environment. Some fire safety checks should be updated. Quality in this outcome area is adequate. This judgment has been made using available evidence including a site visit to the service. EVIDENCE: The homes pre inspection questionnaire gives details of all updated maintenance and refurbished since the last inspection. One comment card stated in their opinion the home was always clean and they were very happy with the facilities. One Resident felt they had seen cockroaches. One Resident stated their mattress was hard and this was evidenced by the inspector. Their bedroom door lock was broken and they did not have a chair in their bedroom. The manager agreed to review these points with the Residents following this inspection. General discussions took place with Staff and further developments to the environment should take place especially in developing younger adult facilities. Staff should continue their role in developing the model to incorporate ideas to
Avondale Nursing Home DS0000005451.V295252.R01.S.doc Version 5.2 Page 20 promote a more “homely” atmosphere and a less institutional approach eg to remove staff official notices from residents areas, to develop and refurbish bathrooms and hallways incorporating younger adults opinions. It was acknowledged that the model of support for younger adults in the community may be difficult to implement especially in a building that offers 50 beds however this should not stop any type of development that staff and Residents may want to explore and improve upon. A sample of maintenance certificates were seen and reflected accurate and up to date checks as listed in the homes pre inspection questionnaire. Fire records were mostly noted to be detailed however regular in house recorded checks must be in place for fire extinguishers and emergency lighting. Avondale Nursing Home DS0000005451.V295252.R01.S.doc Version 5.2 Page 21 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32/34/35/36 This standard was met as most staff had received mandatory training. Supervision must be developed for all staff in line with these standards. The manager had developed all current staff personnel files. Quality in this outcome area is good. This judgment has been made using available evidence including a site visit to the service. EVIDENCE: The home employs a large number of duel qualified nurses and appropriate support staff. Some staff are also duel qualified general nurses. Proof of these qualifications was seen during the inspection. There is always a qualified nurse on duty 24 hours a day. Rotas at the home showed that there are enough staff to care for residents living at the home and that the turnover of staff is low. Staff personnel files were noted to be generally improved and those looked at and were found to contain all relevant information and safety checks including police checks, induction, references and interview check lists, however just one issue recognised that some files did not keep evidence of staff identification. A company review should be carried out to ensure all personnel files are kept in accordance to the care home regulations 2001. . Staff confirmed that they receive a variety of training and the pre inspection questionnaire gave details of all training that had taken place in the home
Avondale Nursing Home DS0000005451.V295252.R01.S.doc Version 5.2 Page 22 since the last inspection. Training and developments plans for the home should be reviewed so that actions can be planned to ensure sufficient staff targets for having NVQ qualifications are in place which will ultimately meet the national minimum standards. The homes pre inspection questionnaire states they have 18.7 of staff with NVQ 2 qualification. The Manager explained that Clinical supervision is taking place however Staff supervision for all Staff must be developed to meet the national minimum standards as currently they are not meeting this standard. Avondale Nursing Home DS0000005451.V295252.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37/39/42 The home is well managed by a long-standing Manager who continues to develop the home and is looking at future developments and needs of all Residents. Residents have various support to identify their views. This can be developed further. Quality in this outcome area is good. This judgment has been made using available evidence including a site visit to the service. EVIDENCE: The homes registered manager is a qualified nurse and has many years experience in caring for adults with mental health problems. The manager holds an NVQ level 4 in management and is supported by a team of other managers within the home. The manager has given various details also contained within the homes pre inspection questionnaire that they have
Avondale Nursing Home DS0000005451.V295252.R01.S.doc Version 5.2 Page 24 proposed to appoint 2 “care co coordinators” to support the Primary Nurse to ensure continuity of care. The Care Co coordinators will then be responsible for the management of medicines. The Manager discussed various plans to look at developing the home for the future and benefit of the Residents needs and agreed to look at developing the home to reflect in ways possible the supp[ort of younger adults in the community. Health and safety is well managed and those records and health and safety company audits seen reflected a safe environment with appropriate checks in place. Just one issue around fire checks was discussed and already reported within this report. There are various ways that Residents are encouraged in airing their views, due to various comments made by Residents during this visit, a review and possibly a development of current systems could take place to include eg a process for informal complaints/ grumbles, develop process for anonymous complaints, for company audits to review current qualities of care and support of staff over 24 hour s and the continued use of questionnaires. The Manager should ensure a policy is developed in supporting people in “Equality and Diversity,” issues. Avondale Nursing Home DS0000005451.V295252.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 2 14 X 15 3 16 2 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 x 3 X 2 X X 3 x Avondale Nursing Home DS0000005451.V295252.R01.S.doc Version 5.2 Page 26 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 YA20 Regulation 13(2) Requirement The registered person must ensure that all medications are consistently audited and include regular recorded temperatures of the drug. The Responsible Person must provide suitable and safe facilities including updated and recorded fire checks. The Responsible Individual must ensure that staff have appropriate identification for all staff personnel files to meet all parts of Schedule 2 of the care home regulations 2001 The Responsible Person is required to provide evidence that all Service Users will be provided with a detailed, accurate and appropriate care plans according to their needs including their social needs, personal care and rehabilitation needs, detailing what actions will be taken to meet this regulation Timescale for action 02/11/06 2. YA40 12 (4)(a) 16 (2) (c) 23 19 02/11/06 1. YA34 02/11/06 3. YA19 15(1)(2) (b) 02/11/06 5. YA16 13(1)(a)(b) The home must ensure
DS0000005451.V295252.R01.S.doc 05/10/06
Version 5.2 Page 27 Avondale Nursing Home YA22 6. YA23 20 residents privacy and dignity are maintained at all times and review staff practices of walking into bedrooms uninvited and the appropriate use of communication to Residents. The homes complaints process should be reviewed and appropriate actions taken following all Residents comments made during this inspection. For the Responsible Person to 02/11/06 provide evidence to CSCI the Manager and Residents, that monies paid for personal allowances to appointee ship will be are arranged to be paid into each Residents account as a matter of priority and carry out a financial review to clarify were interest generated into accounts is paid into.. 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 YA36 YA28 Good Practice Recommendations To continue with ongoing clinical supervision and develop the implementation of supervision as per this standard for all staff. The home should look at creating a more homely environment for residents which is suitable to younger adults and look at a younger adult model that reflects supporting people within the community eg access to local colleges, work placements etc The home should develop a policy for issues around Equality and Diversity. To review the current presentation of liquidised foods so that the presentation can be improved upon.
DS0000005451.V295252.R01.S.doc Version 5.2 Page 28 3 4 YA37 YA17 Avondale Nursing Home Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG 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 DS0000005451.V295252.R01.S.doc Version 5.2 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
