Inspection on 17/07/06 for Avondene

This inspection was carried out on 17th 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Avondene 06/09/07

Avondene 30/01/06

Avondene 09/09/05

Avondene 15/11/04

Avondene 20/05/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Avondene 171 Stanpit Mudeford Christchurch Dorset BH23 3LY Lead Inspector Jo Palmer Key Unannounced Inspection 09.45 17th July 2006 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 Avondene DS0000026761.V304275.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. Avondene DS0000026761.V304275.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Avondene Address 171 Stanpit Mudeford Christchurch Dorset BH23 3LY 01202 483991 01202 483991 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) Christchurch Housing Society Mavis Groombridge Care Home 11 Category(ies) of Old age, not falling within any other category registration, with number (11) of places Avondene DS0000026761.V304275.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th January 2006 Brief Description of the Service: Avondene is registered with the Commission to accommodate a maximum of 11 residents in the category OP (old age). Christchurch Housing Society, a local charity, own and manage several other registered services in the area as well as Avondene. The home is a detached property occupying a corner plot close to Mudeford Quay and the local amenities of Stanpit. Christchurch town centre is a short journey away. There is access via public transport. There is a bus route past the home. All 11 bedrooms in the home are single with over half having en-suite facilities. There is a lounge, sun lounge and dining room. There is a sun porch at the entrance to the home. There are bathrooms on the ground and first floor. Avondene DS0000026761.V304275.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection on 17th July 2006 lasted for four and half hours. Mavis Groombridge, Registered Manager was present and assisted with the inspection. The inspector also spoke with seven residents and one member of staff, examined relevant records and took a tour of the premises. This was a ‘key’ inspection where the home’s performance against the key National Minimum Standards was assessed along with progress in meeting requirements of the last inspection. A pre-inspection questionnaire was sent to the manager in order that certain information could be provided, this was sent at short notice giving little time for the manager to complete the form prior to the inspection. Questionnaires were also sent to the home prior to the inspection to be distributed to residents, relatives and visiting health care professionals, at the time of writing the report four had been returned from residents, one from a community care officer, three from relatives and two from visitors to the home, comments made will be referred to throughout this report and any further responses received will inform the next inspection. What the service does well: One questionnaire from a visitor to the home stated: ‘I would happily come and live here if an when necessary’. Residents and their relatives are assured that Avondene is suitable for meeting their needs prior to admission when an assessment is carried out to identify care needs and other considerations. Each resident has a plan of care detailing for staff how to meet assessed care needs, care plans are written with the resident and are reviewed regularly to ensure they remain current. Care plans evidenced real choice and preferences regarding daily routine and demonstrated the respectful nature of staff/resident relationships. Residents health needs are identified and met by visiting health care professionals and medicines are managed well in the home in the best interests of residents. Staff at Avondene support resident’s rights to privacy in care routines and residents spoken with confirmed they are able to enjoy the privacy of their rooms when they choose without interruption. Avondene DS0000026761.V304275.R01.S.doc Version 5.2 Page 6 Organised social activity is limited although it was evident through discussion with residents that they were generally content in being able to organise their own leisure time with books, newspapers, television or short walks to the park or shops; friends and family are able to visit freely. Meals provided for residents are good and a variety of dishes are served from a set menu which is subject to regular changes and seasonal variations. Should any resident or their relative have any concerns or complaints they can be confident these will be managed effectively as a written complaints procedure outlines the procedure for making a complaint and the way in which it will be resolved and responded to. The correct policy is in place informing staff of procedures necessary should any allegations of abuse or neglect be suspected or reported, some revisions are needed to the internal procedure to ensure conflicting information is not provided, staff have received training in adult protection and abuse issues. Avondene provides a good standard of accommodation that is clean and well maintained and residents benefit from private rooms where they can have some of their own belongings around them, well presented communal areas and satisfactory bathroom and toilet facilities. Enough staff are employed an on duty at any given time to meet residents needs and provide the expected level of support. Staff are safely recruited ensuring appropriate vetting procedures so the registered persons can be satisfied that they are suitable for working with older people and various optional and mandatory training is provided. Mrs Groombridge manages the home well and has support from Christchurch Housing Society in doing so, Mrs Groombridge has attained the expected level of training for care home management. Health and safety process in the home ensure the safety of residents, staff and the premises although requirement is made regarding frequency of some fire equipment checks and maintenance. What has improved since the last inspection? Three requirements of the last inspection have been addressed, these concerned: • • • Care planning and assessment Wedging of fire doors Assessment of risk in relation to possible accidental scalding Avondene DS0000026761.V304275.R01.S.doc Version 5.2 Page 7 What they could do better: Two requirements have been made as a result of this inspection: • • The home’s internal procedure for managing any allegations or suspected incidents of abuse must be revised to ensure it does not conflict with information contained in the local authority guidelines ‘No Secrets’. Records must be available to demonstrate regular internal visual checks on the home’s fire fighting equipment and contractual arrangements must be in place for the six monthly servicing of the emergency lighting system. One recommendation is repeated from the last inspection concerning hot surfaces in the home; radiators should be guarded to ensure against accidental scalding although at Avondene, risk assessments are in lace to ensure corrective action is identified should any risks be highlighted. A recommendation made as a result of this inspection is that the registered persons consider ways of auditing their care practices and services in line with standard 33 and in anticipation of the Annual Quality Assurance Audits that will be required by the Commission later in the year in accordance with the revised Care Home Regulations. 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. Avondene DS0000026761.V304275.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Avondene DS0000026761.V304275.R01.S.doc Version 5.2 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 the following standard(s): 3 & 4. Standard 6 is not applicable Quality in this outcome area is good, this judgement is made using available evidence. The admissions process is such that it ensures resident’s needs are assessed prior to admission and residents are consulted with regard to the care needs outcomes. EVIDENCE: Two resident care files were examined, one for a recent admission to the home. It was evident that the persons care needs had been assessed, albeit briefly to identify her needs. This resident was able to retain a high level of independence with personal care and general well being resulting in the assessment documentation being somewhat sparse. The resident was admitted for a period of respite. A new format has been introduced since the last inspection, which the resident signs to indicate that they have been involved in the assessment process and understand the care outcomes. Records of care provided were evident and detailed although in one instance, no information had been recorded as Mrs Avondene DS0000026761.V304275.R01.S.doc Version 5.2 Page 10 Groombridge confirmed that the resident’s needs had not changed and there had been no significant incidents or events influencing this persons health or welfare. Mrs Groombridge was advised however to ensure that in such cases, there is at least a weekly entry detailing the person’s general well-being and life in the home. One resident spoken with who also included her comments on a questionnaire stated that the admissions process was very good, she felt she had all the information needed prior to making the decision to move to Avondene and she commented on the professionalism and kindness of the manager, Mrs Groombridge in arranging to meet with her two to three times prior to moving in so a relationship had developed and the move was not too daunting. Another questionnaire returned form a health care professional stated: ‘Avondene take time to discuss the persons needs and are very thorough when coming to assess in the hospital’. Avondene DS0000026761.V304275.R01.S.doc Version 5.2 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 the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good; this judgement is made using available evidence. Care plans provide sufficient detail for staff to be aware of resident’s health and welfare needs and how to meet them; care needs are reviewed appropriately. Medicines are managed in the home in the best interests of residents. Resident’s rights to privacy are supported through care delivery, relationships with staff and confidential record keeping practices. EVIDENCE: A requirement of the last inspection has been addressed and a new careplanning format has been introduced in the home. Care plans now indicate the individual residents level of need, based on assessment information and regular reviews. Care Plans provide detailed instruction for staff regarding how care needs are to be met in respect of personal care, health care, social and general welfare needs. One care plan examined was limited in information although it was evident that this person was on a short stay period of respite Avondene DS0000026761.V304275.R01.S.doc Version 5.2 Page 12 at Avondene. The second care plan examined demonstrated an inherent respect for the resident and gave total consideration for her preferences and choices in care delivery, diet, routines and social activity. Care plans are reviewed monthly and detail is provided concerning the residents health and welfare, at the time of review, if there have been any significant changes, the care plan is revised. A risk assessment format has also been introduced which details any perceived risk to the resident including risks of infection, accident, falling, pressure ulcers and describes the action needed to reduce those risks. Records of care, reviews and care plans where appropriate, address resident’s health care needs and detail any necessary intervention required by members of the community health care teams including GP’s district nurses, physiotherapists etc. Medication systems are well managed in the home with records mostly supporting an audit trail of medicines prescribed, received into the home, administered on behalf of residents and disposed of when no longer required. Records confirmed that medicines were given as prescribed and where residents retain responsibility for their own medicines, this has been risk assessed to ensure the residents continued capacity to do so. Seven residents were spoken with all of whom confirmed they are treated respectfully by a caring staff group who are able to meet their needs in the manner to which they expect. Residents confirmed that their privacy is respected in their rooms and when receiving assistance with personal care routines. Comments received on questionnaires returned form visitors included: ‘The residents are thoughtfully looked after and as always there is a warm and friendly atmosphere’. ‘Very warm and friendly atmosphere at this home, real sense of freedom, well done to a friendly staff and manager’. ‘I am very happy with the care my mother receives, the staff (particularly the manager Mrs Mavis Groombridge) are always helpful, welcoming and communicative and very sensitive to my mothers needs. The home is beautifully clean and has a cheerful, homely atmosphere’. ‘They work well with families and are always happy to discuss any issues’. Avondene DS0000026761.V304275.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good, this judgement is made using available evidence including a visit to this service. Social care assessments provide staff with basic information concerning individual social and leisure choices and residents were content with the homes social arrangements. Residents are supported in maintaining contact with their friends and family and in making decisions about their lives in the home. Residents are provided with a varied menu and choices of meals that meet their dietary needs. EVIDENCE: A written schedule of activities, or ‘activities programme’ was not examined although it was evident from discussion with residents that they were generally satisfied with the level of activity in the home although several stated that they were ‘left to their own devices’ and there was not much organised activity arranged by the home. However, those spoken with were happy with the arrangements and were able to enjoy books, magazines, newspapers and each others company; several residents were seated in the lounge area together and after lunch, three went into the garden to sit together in the shade. One Avondene DS0000026761.V304275.R01.S.doc Version 5.2 Page 14 questionnaire returned from a relative stated that: ‘I sometimes feel the staff do not spend enough time interacting with residents, they appear to be left a lot of the time with no stimulation’. Assessments and care plans demonstrate the extent to which residents individual social and leisure preferences have been taken into account, it was also evident from care documentation the extent of family involvement and residents confirmed they are able to receive visitors freely. Some residents confirmed that they are able to get out with the support of their families to visit local places of interest and to socialise and some residents confirmed they are able to enjoy trips to the local shops, park etc either independently or with a staff member. Residents confirmed that they are able to make decisions and choices and retain some control over their lives confirming that they can get up and go to bed when they please, move freely about the home, form and maintain friendships and are involved in decisions about their care. Menu’s examined and discussion with residents confirmed that a variety of appetising meals are provided, those residents not wanting the set midday meal are at liberty to have an alternative and this was confirmed by the cook who said a variety of alternatives are available; however, as individual likes and dislikes are known, residents are usually able to enjoy the set meal of the day. Breakfasts are served by individual choice and the evening meal consists of a lighter dish such as sandwiches, soup, salad etc. Mrs Groomridge and the cook confirmed that menus are changed regularly dependent on seasonal variations and available produce from the supermarket. Food stores were seen and it was evident that a range of dried foods, fresh and frozen are used; there was a good supply of fresh fruit and vegetables. Residents also confirmed and it was evident around the home that plenty of drinks were available for residents on what was, one of the hottest days of the year. Avondene DS0000026761.V304275.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 is made using available evidence including a visit to this service. Any person wishing to complain is directed through a written procedure detailing how their concerns will be addressed, they can therefore be confident that their complaints will be listened to and taken seriously. Procedures for responding to suspicions of abuse are held in accordance with Department of Health guidance, meaning that any allegations of abuse can be managed effectively although some revisions to the policy are due. EVIDENCE: The homes Statement of Purpose and Service User Guide (standard 1) were not reviewed at this inspection although the last inspection reported that information was provided as required; Mr Groombridge confirmed that this has not changed since the last inspection. The Service User Guide contains the home’s complaints procedure, which is available to all residents and their representatives, questionnaires returned from residents and their relatives all indicated that they knew how to make a complaint should they need to. Mrs Groombridge confirmed that no complaints have been received. A policy document is available for staff reference directing them through procedures to be followed in the event of any suspicion of abuse; this refers staff to the local authority guidelines ‘No Secrets’ which gives more detail of the reporting procedure. Although ‘No Secrets’ provides staff with the required information, this is confused by the home’s own policy which needs amending. Avondene DS0000026761.V304275.R01.S.doc Version 5.2 Page 16 This currently states that the manager should investigate any reported incidents, which is in contravention of the local authority guidance. The home’s internal policy also states that if any allegations are received directly from residents or relatives, these should be dealt with using the home’s complaints procedure; again, this is in contravention of the local authority guidelines which states that all alleged incidents must be reported to the local authority adult protection team for investigation. Mrs Groombridge confirmed that all the home’s policies and procedures are due to be updated shortly. No incidents have been reported or allegations received. Avondene DS0000026761.V304275.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, 21, 23, 24, 25 & 26 Quality in this outcome area is good. This judgement is made using available evidence including a visit to this service. Accommodation at Avondene is safe and well maintained. Residents are able to benefit from comfortable, well furnished, clean and hygienic surroundings with some of their own belongings around them. EVIDENCE: A written schedule of completed maintenance of the premises was seen indicating repairs and refurbishment. There was also evidence of regular servicing of equipment (see standard 38) There are sufficient bathing and toilet facilities sited around the home which are provided with appropriate aids and adaptations to meet residents needs. Resident’s rooms are comfortable and furnished appropriately and residents are able to benefit from having some of their own belongings around them. The lounge and sun lounge areas of the home provide a sociable meeting place Avondene DS0000026761.V304275.R01.S.doc Version 5.2 Page 18 for residents and a dining room is available where most residents can enjoy their meals. On one of the hottest days of the year with temperatures around 32°C, the home was appropriately ventilated and a reasonable temperature, residents confirmed they were cool enough with a breeze through the home from open doors and windows. Radiators and exposed pipe-work are not all guarded to prevent accidental scalding although risk assessments are in place for individual residents to identify any necessary control measures needed to secure against the risk of accidental scalding when the heating is on in colder weather. All areas of the home visited were clean and well maintained and free from offensive odours, questionnaires returned from residents and relatives included comments that the home is ‘always clean and welcoming’, ‘the home is beautifully clean and has a cheery, homely atmosphere’, and that cleanliness is ‘excellent’. Staff are provided with appropriate hand washing facilities including anti-bacterial soap, disposable towels and an alcohol based hand sanitizer. The laundry room was not inspected although it was evident from observations of residents dress and bedding that the laundry service is effective, residents spoken with confirmed that their laundry is done quickly and is returned in good condition. Avondene DS0000026761.V304275.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 good. This judgement is made using available evidence including a visit to this service. There are sufficient numbers of staff on duty in the home each day and night to provide the level of care and support needed by residents. Staff training programmes are in place to ensure that the staff group has the skills and knowledge they need to meet resident’s needs. Staff recruitment practices are good and ensure resident’s safety with all staff being appropriately screened prior to taking up employment. EVIDENCE: There are sufficient numbers of staff on duty for each shift with two carers on each morning and afternoon and one each night with a second night carer sleeping in/on call. One member of staff has a joint role as cook and carer, this person is also in the home each morning as the cook and works as a carer from 1.30pm until 4.00pm. There are no dedicated cleaning or laundry staff, these tasks being undertaken by carers, as a small home, Mrs Groombridge confirmed that care staff have the time capacity to do this although if more care hours were needed (if resident dependency levels increase) another member of staff would be put on shift. One questionnaire retuned from a resident stated: ‘The thing I appreciate the most is the continuity of staff, to see the same faces every day makes for a much more settled, happy life’. Avondene DS0000026761.V304275.R01.S.doc Version 5.2 Page 20 One member of care staff has attained NVQ level 3 in care and two are currently doing level 2. Mavis Groombridge confirmed that twelve staff are employed although there are no plans for other staff to undertake this award. All staff attend various training courses relevant to their roles including infection control, moving and handling, food hygiene and care specific course as they become available. Two staff files were examined, both staff had been recruited following the homes procedure. On each staff file was an application form detailing previous employment and qualifications and providing referees. Each staff had made a declaration of health and each file held two satisfactory references, one form the applicant’s last employer. Both applicants had applied for and received, satisfactory CRB* and POVA* certificates. Evidence of the applicants identification were held on each file. Six staff from Avondene are currently working through an induction programme; Mrs Groombridge stated that this is in being run by an external training consultancy as a distance learning package which meets National Occupational Standards for care staff. * Criminal Records Bureau and Protection Of Vulnerable Adults - The CRB check includes a check against the POVA list to ensure the person applying for the position has not been excluded from working with vulnerable people. Avondene DS0000026761.V304275.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 & 38 Quality in this outcome area is good. This judgement is made using available evidence including a visit to this service. Avondene is managed effectively and in the best interests of residents. Quality assurance processes are developing although to ensure controlled measurement of care and services provided these need further development. The manager confirmed that the home does not take responsibility for the management of any resident’s finances. The health and safety of residents is protected by procedures ensuring that equipment is checked and maintained although checking and maintenance of fire safety equipment needs to be done more frequently. Avondene DS0000026761.V304275.R01.S.doc Version 5.2 Page 22 EVIDENCE: Mavis Groombridge is registered with the Commission to manage the home on a daily basis with the support of Christchurch Housing Society. Mrs Groombridge has attained an NVQ level 4 in care and the Registered Managers Award. Staff and residents spoken with confirmed that Mrs Groombridge manages the home tirelessly and is always available for support and advice. One questionnaire returned from a relatives stated that: ‘I have complete confidence in Mavis’ judgement on all matters concerning my mothers care’. Questionnaires have been sent to residents and relatives and although all responses have been positive, quality reviews have not lead to a ‘published’ development plan available to residents their relatives or the Commission. On 1st April 2006 a change in the regulation introduces a legal requirement for registered providers to produce an Annual Quality Assurance Assessment (AQAA), this will be introduced to care homes in autumn 2006. Although the Commission will introduce a set proforma it would be considered good practice for the registered persons to consider in a development plan, how well in their estimation, they deliver good outcomes for residents at Avondene including where improvements can be made and what action will be taken to respond to requirements and recommendations of the inspection. Mrs Groombridge confirmed that the home does not assist any of the residents with the management of their finances; residents either manage their funds personally or have the support of their families or representatives. Examination of records of testing and maintenance of fire fighting equipment and emergency lighting demonstrated that these are not being undertaken at the required intervals. Checks of the alarm system, fire doors and exits, smoke detectors etc are carried out at the required weekly frequency. Records of internal checks of the fire fighting equipment are not maintained, these checks should be a monthly, visual check of appliances to ensure they are in their correct location and have not been tampered with. A service contract is in place demonstrating the required level of maintenance of the fire warning system and fire fighting equipment, the contractual arrangements for the six monthly servicing of the emergency lighting is not in place. A fire risk assessment has been recently carried out by a contracted engineer, the registered persons are urged to address the identified action points as soon as possible and forward their action plan to the local fire and rescue service. Records of staff fire safety/awareness training show that all staff have received training in the last six months. Nine members of staff have recently undertaken a training course in ‘Safety Compliance’ looking at all aspects of Health and Safety. Service contracts were seen which detailed health and safety measures and maintenance of equipment and installations. Avondene DS0000026761.V304275.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 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 3 X 3 X 3 3 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 1 Avondene DS0000026761.V304275.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Clear policy guidance must be available for staff relating to issues of adult protection and staff must be directed to report any such issue to the correct authority. The registered persons must ensure that a regular monthly check is carried out and records held relating to the visual checking of fire fighting equipment and that contractual arrangements are in place for the six monthly servicing of the emergency lighting system. Timescale for action 1. OP18 13 01/09/06 2 OP38 23 01/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 Refer to Standard OP25 OP33 Good Practice Recommendations It is recommended that radiators and exposed pipe-work are guarded. It is recommended that the registered persons consider establishing a development programme from their quality audits in line with the expectations of the Commission’s ‘Inspecting for Better Lives’ programme. DS0000026761.V304275.R01.S.doc Version 5.2 Page 25 Avondene Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF 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 Avondene DS0000026761.V304275.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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