Inspection on 06/07/06 for Avondale Nursing Home

This inspection was carried out on 6th July 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 19/01/06

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 Key Unannounced Inspection 10:00 6 – 13th July 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 DS0000025947.V303194.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. DS0000025947.V303194.R01.S.doc Version 5.2 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 DS0000025947.V303194.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th January 2006 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. 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 are two double bedrooms, both of which have an en-suite toilet, and 16 single rooms, many of which also have an en-suite toilet. The home is privately owned and managed by two business partners. They employ a matron to oversee the day-to-day care of the service users. The Statement of Purpose and the Service User Guide are issued to every prospective service user and both of these documents are readily available. A copy of the most recent inspection report is also available and a resident or relative/representative could request a copy which the managers would make available. The fees for the home are £500-£600. The proprietor/manager made this information available on 24th July 2006. DS0000025947.V303194.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over two days and lasted nine hours. The inspector spoke to a number of residents about their experience of living at the home and to relatives who were visiting the home and by telephone. Discussions took place with the registered proprietors/managers, matron and several members of the care and nursing staff. Staff were spoken to about the care practices and their employment at the home. They were also observed directly and indirectly providing care to the residents. A tour of the home took place and a number of staff and residents’ files, staff rotas, menus and complaints log were examined. Fifteen requirements were set at the last inspection, five of these requirements have not been met and two of these requirements are for the third time. These requirements 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? DS0000025947.V303194.R01.S.doc Version 5.2 Page 6 Six of the previous requirements have been met. The menus are accurately recording the meals that are being served. The Complaints log is now being recorded in more detail and the Commission is receiving Regulation 37 notices. Recruitment procedures are now satisfactory. All of the hot water outlets temperatures are being checked and recorded regularly. 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. DS0000025947.V303194.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000025947.V303194.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3,4,5 & 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prior to admission the manager or the matron will undertake an assessment of the prospective resident’s needs, however there is little information in the assessment regarding people’s social care needs. This could have an impact on the resident’s emotional well - being. Prospective residents and their relatives/representatives are able to visit prior to their admission to ensure that the home is suitable. The home does not provide intermediate care. EVIDENCE: There have been three admissions since the last inspection. All of these files were examined and there was evidence that prior to admission, the manager or the matron had visited prospective residents and an assessment completed. These assessments had been completed with information obtained from the resident (where possible), relatives, social and health care professionals. The assessments identified resident’s physical and personal care needs, however, DS0000025947.V303194.R01.S.doc Version 5.2 Page 9 there was limited information as to the social care needs of the resident. This indicates that the information transferred to the care plans is not comprehensive, as not all of the residents’ needs have been identified. This is Requirement 1. One of the residents told the inspector that they had not been able to visit the home prior to admission, as they had been in hospital. However, their family had visited the home on two occasions at different times and felt that it was the one, as the staff seemed very friendly, were happy to answer any questions and felt that she would be happy there. The resident said ‘my family had made the right choice, they really look after me’. Another relative told the inspector that ‘I visited other homes, but I liked this one because it is small and homely’. The home is not registered to provide intermediate care. DS0000025947.V303194.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service There has been some improvement in the residents’ care plans, however, further work needs to be undertaken to ensure that all of the resident’s needs are identified and recorded. This will ensure that the care staff have sufficient information to meet the residents’ needs on a daily basis. Not all of the residents’ health needs are being regularly monitored and reviewed, which has the potential for residents’ health needs not being effectively met. There are medication policies and procedures to follow, however, there are some inconsistencies in the recording of medication, which may result in unsafe practices. Residents are treated with respect and the arrangements for their personal care ensure that their right to privacy is upheld. EVIDENCE: DS0000025947.V303194.R01.S.doc Version 5.2 Page 11 Individual care plans were available for each resident and the records of five residents were examined. There has been some limited improvement in the standard of care planning since the last inspection, however, further work needs to be carried out to ensure that the residents’ social needs are identified and incorporated into their care plan. Residents’ weights are not being recorded on a regular basis and not all of the residents have a dependency profile. Care plans are being re-evaluated monthly and updated to reflect residents’ changing needs. Daily entries made by staff relate to the needs identified in the resident’s care plan. Though there has been some improvement in the recording and evaluation of the care plans, further work is still required to ensure that the residents’ current and changing needs are identified and recorded. This was a previous requirement that has been taken forward with a new timescale. This is Requirement 2. Records indicate that residents have been seen by other health professionals and one new resident has been seen by her G.P. diabetic specialist nurse, physiotherapsist, chiropodist, continence advisor, optician and Moorfields eye hospital during the past five months. Risk assessments particularly in pressure area care are not always being routinely evaluated, this lack of robust monitoring could put residents at risk. This was a previous requirement that has been taken forward with a new timescale. This is Requirement 3. There was evidence from residents’ files that some six monthly reviews have taken place, however the registered persons must ensure that reviews are carried out on residents that are privately funded. This will ensure that the home can continue to meet the needs of the resident. This was a previous requirement that has been taken forward with a new timescale. This is Requirement 4. There are policies and procedures for the handling and recording of medication in the home. Only nursing staff can administer medication. An audit was undertaken of the Medication Administration Record (MAR) chart and there were gaps in the recording of medication administered, such omissions may result in putting residents at risk of receiving the incorrect dosage of prescribed medication. This is Requirement 5. Staff were seen to treat residents in a respectful and sensitive manner. Staff understood the need to respect resident’s dignity and were seen to knock on bedroom and bathroom doors before entering. The inspector spoke to a number of residents and relatives who all said that staff were thoughtful and respectful. One resident stated that ‘the staff are very respectful, they don’t talk to me as if I was a child’. Another resident stated that ‘the carers are thoughtful when helping me to have a wash’. DS0000025947.V303194.R01.S.doc Version 5.2 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): 12,13,14 & 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. There is a programme of activities available for large groups but more consideration needs to be given to planning individual and small group activities, which would ensure that all residents have a sufficiently stimulating and varied choice of activities. Visiting times are flexible and people are made to feel welcome in the home, which ensures that residents are able to maintain contact with their families and friends as they wish. Residents could be assisted to exercise more choice and control over their lives. The meals in the home are well presented and nutritionally balanced and offer a healthy and varied diet. EVIDENCE: 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 DS0000025947.V303194.R01.S.doc Version 5.2 Page 13 each activity. Daily logs were examined and discussion took place with the matron and residents and relatives were asked for their views. New care plans have been drawn up these do not clearly identify resident’s social care needs (this has been reported on under standard 7). The matron reported that activities such as, music and movement, games, bingo and reminiscence sessions regularly take place and that the residents’ social activities have been reviewed and records are now kept of their involvement of each activity. Records that were examined did show whether residents had taken part, but the activities appear to be limited and mostly in groups. Most of the residents and relatives that were spoken to stated that there was not enough regular activities and two of the relatives commented that the garden furniture was seldom out, which would give the residents a change of scenery. On the day of the inspection the hairdresser was visiting and many of the residents were having their hair cut and set and care staff were observed sitting talking to the residents on a one to one basis. There was no evidence that residents are being consulted, with regards to what activities they would like to undertake within the home and in the community. The registered persons confirmed that residents’ meetings do not take place. This previous requirement has been taken forward with a new timescale. This is Requirement 6. Visiting times are flexible and visitors confirmed that they could visit at any time. All of the relatives spoken to stated that ‘they are made to feel welcome’. Residents are able to see their families and friends in the lounge or in their bedroom. The majority of the residents receive visits from family or friends and the home is currently trying to arrange an advocate for residents that do not have a representative. Residents care plans indicate their preferred name and whether they choose to have a bath or shower. Residents are encouraged to bring their own personal possessions with them when coming to live at the home and this was evident when the inspector visited the residents’ bedrooms. Items such as, a radio, televisions, photographs, pictures and ornaments enable the rooms to feel more homely and one resident has his budgerigar living with him. None of the residents are able to handle their own finances but there is a policy and procedure in place, if any future resident is able to. Meals are mostly served in the lounge, though some of the residents prefer to have their meals in their bedroom. There are two choices of the main meal and on the day of the inspection the chef was seen to cook something different, as the resident did not like either of the choices. The meals that were seen on the day of the inspection looked appetising and nutritionally balanced, the cottage pie was homemade and this was served with three different vegetables. The meals that were served correlated with the menu for the day. This was a previous requirement that is now met. Both residents and relatives were complimentary of the food. Residents confirmed that they could have a snack of either biscuits or a sandwich with their evening drink. During the inspection, DS0000025947.V303194.R01.S.doc Version 5.2 Page 14 residents were frequently offered drinks and biscuits were offered with their morning and afternoon tea. The chef was very aware of residents’ dietary needs and advised the inspector of who was diabetic and who required pureed diet. Residents that required assistance with eating their meal were treated courteously and were not rushed. DS0000025947.V303194.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 &18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents and their relatives can be confident that their complaints will be listened to, and acted upon. The home has a policy and procedure regarding allegations of abuse, however, the registered persons must ensure that staff receive training in Adult Protection/Abuse Awareness to ensure that there is an appropriate response to any allegation of abuse. EVIDENCE: The registered persons have a complaint procedure which specifies how people can make a complaint and who will deal with them. The complaint log was examined and there has been improvement in the logging of these. Complaints clearly indicate details of the complainant, the nature of the complaint, the outcome and whether the complainant was satisfied with the outcome. This was a previous requirement that has now been met. One relative stated that ‘I did make a complaint but it was dealt with satisfactorily and I was happy with the outcome’. Five residents were asked ‘if you were unhappy about anything in the home, who would you talk to’? Two of the residents said they would talk to a nurse, one resident said she would talk to the manager and the other resident said she would talk to her family. DS0000025947.V303194.R01.S.doc Version 5.2 Page 16 At the last inspection a requirement was set regarding the legal requirements to notify the Commission of significent events. The registered persons were only reporting the death of a resident and not of any other significent events. Regulation 37 requires all registered providers to notify the Commission about significent events that may adversely affect the well-being or safety of any residents. The Commission is now receiving all regulation 37 notices. This requirement is now met. The majority of the residents have relatives or friends who can advocate on their behalf, if they so wished. The registered persons are arranging an advocate for the person who has no visitors. There is a written policy and procedure for dealing with allegations of abuse; the home also has a copy of the local authorities (Redbridge) documentation on the Protection of Vulnerable Adults. Adult Protection/Abuse Awareness is dealt with as part of all staff’s induction programme, however, on inspection of staff files not all of the staff have attended formal training on Adult Protection/Abuse Awareness. This matter is of some concern as this issue had been discussed at the last inspection and a requirement was set, which has not been met. This is Requirement 7. Staff that were spoken to were aware of the different forms of abuse and what action to take if there were any concerns about the welfare and safety of the residents. DS0000025947.V303194.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20, 23,24,25 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Generally the home is clean, pleasant and spacious with access to indoor and outdoor communal facilities, which adequately meets the needs of the residents. Residents’ bedrooms mostly suit their needs, however the registered persons must ensure that all of the furniture and carpets are fit for the purpose. EVIDENCE: The registered persons has an ongoing redecoration programme as well as a daily and weekly maintenance programme, which should ensure that the residents live in a comfortable and safe home. The registered persons employ a handyman and there is a system for staff to report items requiring repair or attention. DS0000025947.V303194.R01.S.doc Version 5.2 Page 18 The inspector undertook a tour of the home during the inspection. There are two comfortable lounges, which are also used as the dining area. In the smaller lounge some of the armchairs require recovering or replacing, and some of the light bulbs were not working, these need to be replaced to ensure that there is adequate light for the residents. Most of the residents’ bedrooms are appropriately furnished and have photographs, pictures, radios and televisions that the residents have bought from their own homes, one resident has his budgerigar with him. However, some attention is required as there was a stain on one of the bedroom carpets and in two of the other bedrooms, one had too many armchairs, which made the room cluttered and a potential safety hazard and in the third bedroom the armchair had a split in the arm. The registered persons must ensure that the home is safe and well maintained. This is Requirement 8. The kitchen was found to be clean and all food was appropriately stored. The Environmental Health Officer visited the home in May 2006 and food safety practices/procedures were found to be satisfactory. Refridgerator and freezer tempretures are regularly taken and recorded. The home is cleaned on a daily basis and throughout the inspection most areas of the home were found to be clean and tidy and free from any offensive odours. However, two relatives commented that sometimes the lounge has an offensive odour. The registered persons must ensure that there are adequate control systems in place to ensure that the home is free from offensive odours at all times. This is Requirement 9. DS0000025947.V303194.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The home’s staffing levels are satisfactory and there are sufficient staff on duty, however the training and the skills mix of the staff must be reviewed to ensure they can meet the needs of the residents. The home has a clear recruitment policy and procedure and appropriate checks are undertaken, which ensures the protection of residents. EVIDENCE: The home has a stable workforce. On the day of the inspection staffing levels were seen to be appropriate to meet the needs of the residents. The staff rotas were examined and the rota correlated with the number of staff on duty. The rota also identified which proprietor/manager was responsible for the home that day. Three staff files were examined showed that all of the relevant recruitment procedures are being followed. All files had a completed application form, two written references and all had Criminal Record Bureau (CRB) checks. This was a previous requirement that has now been met. Staff files showed that staff have undertaken training in areas such as fire procedures, health and safety, pressure area care and moving and handling, DS0000025947.V303194.R01.S.doc Version 5.2 Page 20 diabetes awareness and Parkinson’s disease. Some of this training is not recent, only four care staff have achieved their NVQ2 and some of the staff have not attended 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 was a previous requirement which has not reached the timescale for compliance. DS0000025947.V303194.R01.S.doc Version 5.2 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. 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, care plans, risk assessments and health and safety. All of these aspects affect the quality of life of the residents. Residents’ finances are safeguarded by the policy and procedures of the home. There are not the appropriate systems in place to ensure that residents are supported by staff who are appropriately supervised. DS0000025947.V303194.R01.S.doc Version 5.2 Page 22 EVIDENCE: The registered proprietors/managers are registered nurses and have substantial experience in managing a care home. They have an understanding of the needs of the residents. They both spend a considerable amount of time at the home and are supported by an experienced matron. Comments from residents and relatives were complimentary, saying they are helpful and approachable. As stated earlier in the report, there has been some improvement in the care planning but further work needs to be carried and risk assessments particularly in pressure area care are not routinely carried out. Supervision of staff has not commenced and training on Adult Protection/Abuse Awareness has still not taken place. The registered persons must have adequate systems in place to ensure that the staff are able to meet the needs of the residents. This was a previous requirement that has been taken forward with a new timescale. This is Requirement 10. The home had a relatives meeting last year, which was well received and the plan is to hold another one in the coming months. Residents meetings have not commenced and resident satisfaction questionnaires, as well as relatives and stakeholders quality assurance surveys have not taken place. An annual development plan that reflects the aims and outcomes for the residents has not been developed. This was a previous requirement that has not reached the timescale for compliance. Staff files were examined and neither nursing nor care staff have received formal supervision or yearly appraisals. The matron has held a staff meeting to discuss supervision and one to one meetings are due to commence next month. This was a previous requirement that has been taken forward with a new timescale. This is Requirement 11. A requirement was set at the previous three 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 records were checked on this inspection and it was noted that all hot water outlets have their temperatures checked regularly. This requirement is now met. DS0000025947.V303194.R01.S.doc Version 5.2 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 X X 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 2 X X 3 2 2 2 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 1 X 2 DS0000025947.V303194.R01.S.doc Version 5.2 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 OP3 Regulation 14(c) Requirement The registered persons must ensure that all of the residents needs are identified in the assessment. The registered persons must ensure that all needs, including changing needs are accurately recorded in each individual care plan. Previous timescales of 31/08/05 and 30/04/06 not met. The registered persons must ensure that all risk assessments are completed and reviewed at least monthly. Previous timescale of 30/04/06 not met. The registered persons must keep the resident’s plan under review. Previous timescale of 30/04/06 not met. The registered persons must ensure that the MAR sheets are completed appropriately at all times. The registered persons must ensure that the residents’ social and recreational interests and DS0000025947.V303194.R01.S.doc Timescale for action 31/10/06 2 OP7 15(2) 31/10/06 3 OP8 13 (4) 30/09/06 4 OP7 15(2) (b) 31/10/06 5 OP9 13(2) 31/07/06 6 OP12 16(2)(n) 30/11/06 Version 5.2 Page 25 needs are identified and met. A record of activities must be kept, which clearly shows each resident’s involvement in each activity. Previous timescales of 30/09/05 and 31/05/06 are not met. 7 OP18 13 (6) All staff must receive formal training in Adult Protection/Abuse Awareness. Previous timescale of 31/06/06 not met. The registered person must ensure that the furniture, carpet and other fittings are fit for the purpose. The registered persons must keep the home free from offensive odours. 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 all staff are appropriately supervised at least six times a year. 30/09/06 8 OP24 23 31/08/06 9 10 OP26 OP31 16 (2)(k) 10 31/07/06 30/07/06 11 OP36 18 (2) 30/07/06 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 DS0000025947.V303194.R01.S.doc Version 5.2 Page 26 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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