Inspection on 13/05/08 for Avonwood Manor

This inspection was carried out on 13th May 2008.

CSCI found this care home to be providing an Good service.

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

Avonwood Manor 08/12/09

Avonwood Manor 12/11/09

Avonwood Manor 20/10/09

Avonwood Manor 21/09/09

Avonwood Manor 17/06/09

Avonwood Manor 25/07/07

Avonwood Manor 25/04/06

Avonwood Manor 28/10/05

Avonwood Manor 25/05/05

Avonwood Manor 27/01/05

Avonwood Manor 16/04/04

Similar services:

Trevaylor Manor

Stallcombe House

Stroud Lodge

The Woodmill

Woodland Vale

Bolealler House

Claremont Nursing Home

Althea Park House

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Avonwood Manor 31-33 Nelson Road Branksome Poole Dorset BH12 1ES Lead Inspector Martin Bayne Key Unannounced Inspection 13th May 2008 10:00 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 Avonwood Manor DS0000043057.V364521.R02.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. Avonwood Manor DS0000043057.V364521.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Avonwood Manor Address 31-33 Nelson Road Branksome Poole Dorset BH12 1ES 01202 763183 01202 751530 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) Avonwood Manor Ltd Mrs Margaret Dorothy Ann Phillips Care Home 49 Category(ies) of Dementia - over 65 years of age (49), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (49) Avonwood Manor DS0000043057.V364521.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One named person (as known to CSCI) under the age of 65 may be accommodated to receive care. 25th July 2007 Date of last inspection Brief Description of the Service: Avonwood Manor is registered to provide accommodation and personal care for up to 49 residents who suffer from mental disorders or dementia above the age of 65. Since the last inspection in July 2007 there have been changes to the management arrangements of the home. Avonwood Manor is still owned by Avonwood Manor Ltd, however the home is now managed through Affinity Care Homes and not BML Healthcare as at the time of the last key inspection. The home is situated in a quiet residential area close to the shops and amenities of Westbourne. The home is made up of two large properties that have been joined by an extension. Each of the properties has three floors and there is a passenger lift at either end of the home. Communal areas are located on the ground floor and there are well maintained and enclosed gardens leading from the back of the home that residents can access. The majority of the bedrooms are for single occupancy with en-suite WC facilities; however there are eight double rooms, in which screens are provided for residents’ privacy. At the front of the home there is parking for staff and visitors. The fees for the home range from £500 a week to £630 per week. Details of further charges are contained within the Terms and Conditions of Residence. Avonwood Manor DS0000043057.V364521.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. We, the Commission, carried out this key inspection between 10am and 3:30pm on the 13th of May 2008 and between 11am and 1pm on the 14th of May 2008. The inspection was carried out alongside a contract monitoring visit conducted by Poole Borough Council. We were assisted throughout the inspection by Mrs Phillips, the home’s Registered Manager and also with assistance from a regional manager for Affinity Care Homes. At this inspection we looked at samples of records relating to the care are of residents, the training and recruitment of staff and records relating to health and safety within the care home. An hour was spent in the communal areas during lunchtime on the 13th of May when we observed residents being assisted during the lunchtime period. We spoke with three members of staff and also with three sets of relatives who were visiting the home that day. A tour of the premises was made and some residents spoken with, however due to their mental frailty they were unable to give an account of their experience of living at the home. During the inspection we followed up on the one requirement and three recommendations that were made at the key inspection in July 2007. Comment cards were sent out to relatives, care managers and health care professionals. One was returned by a staff member, one by a care manager and seven from relatives. These were also used to support the judgements contained within this report. What the service does well: The home carries out preadmission assessments of people’s needs prior to being offered a place at the home. Care plans are developed from the assessment process and provided clear information and direction for staff. Health needs of residents are met with residents registered with local GP surgeries. Appropriate referrals are made when residents have health concerns. Medication is administered by trained staff and stored appropriately. Avonwood Manor DS0000043057.V364521.R02.S.doc Version 5.2 Page 6 Generally there were favourable comments made about the staff, but better continuity of care will be provided when staff vacancies are filled. The home is well maintained and was found to be clean and in good decorative order. In general we found that the home was well managed and the new management support arrangements should benefit residents. What has improved since the last inspection? What they could do better: Senior staff could better monitor that staff are carrying out instructions as detailed within care plans. Where hand entries have to be made to medication administration records, a second member of staff should sign that the record has been checked and entries made correctly. It was agreed that an audit would be carried out of the medication cabinet to ensure that there are no out of date medications being stored. Residents would benefit from the appointment of a second activities coordinator providing better stimulation for residents. New building risk assessments have been carried out with specific reference to the safety of the stairs. The proposed actions should be carried through to provide a safer environment. Should the home use agency staff, the Registered Manager must ensure that the agency supplies a letter to inform that all of the requirements of Schedule 2 of the Regulations have been complied with. The Registered Manager should also ensure that staff applicants give an account for gaps in their employment history. The staff at the home would benefit from training in the Mental Capacity Act 2005 and more training in the care of people with dementia. The Registered Manager should set up a training programme to ensure that at least 50 of staff are trained to NVQ level 2 or above. Avonwood Manor DS0000043057.V364521.R02.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Avonwood Manor DS0000043057.V364521.R02.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 Avonwood Manor DS0000043057.V364521.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from good preadmission assessment processes that ensure that residents’ needs are met at the home. EVIDENCE: The admission procedures remain the same as at the time of the last inspection. When the home receives an enquiry about a vacancy, a brochure and a copy of the Service User Guide is sent out. Relatives and prospective residents are invited to view the home. Throughout the inspection we used a sample of three residents’ personal files to track the paperwork and records the home must keep as evidence of how Avonwood Manor DS0000043057.V364521.R02.S.doc Version 5.2 Page 10 they have met the care needs of residents. We found that a preadmission assessment of the persons needs had been carried out by the Registered Manager prior to the person being offered a place at the home, thus ensuring that the home was in a position to meet that person’s needs. The preadmission assessments that we saw covered all of the topics that are detailed within the National Minimum Standards for older people. We saw that where residents were funded through local councils, a copy of the care management assessment and care plan had been obtained as part of the preadmission assessment process. We also found that a letter had been sent to the relatives of the person referred informing that their needs could be met at the home. The home does not provide an intermediate care service. Avonwood Manor DS0000043057.V364521.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 9 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from a good standard of care planning to inform the staff of how to care for residents but there could be an improvement by senior staff ensuring that care plans are followed through by the staff. Generally, there are good systems for administering medication in the home. EVIDENCE: We saw the personal files for the three residents we tracked through the inspection. The files had a photograph of the person on the front and were divided into the following sections: • Personal details and pre-admission assessment. Avonwood Manor DS0000043057.V364521.R02.S.doc Version 5.2 Page 12 • • • • • • • • • • • A brief life history. Wishes of the person in the event of death. Care plans for both day and night care needs. A general risk assessment. A falls risk assessment and moving and handling assessment. A care plan. A nutritional assessment. A record of visits from visiting health professionals. Daily recording. An inventory of property and possessions brought into the home. A record of the activities carried out with that person. We found the files to be well-organised and up-to-date with reviews of care plans taking place each month or when needs of the person change. Plans were typed, concisely written and provided sufficient information for a member of staff to meet the care needs of that person. There was space at the bottom of the care plans for the resident or their relative to sign. Plans are kept within the two separate sections of the home so that they are readily accessible to staff. Within two care plans we saw, there was an instruction that monitoring charts concerning fluid intake be maintained by the staff. We asked to see the charts being kept by the staff and were shown monitoring charts for that day for these two residents in the small kitchen. Copies of the previous days’ charts however could not be found. A requirement was therefore made that where care plans instruct staff to keep monitoring charts, these must be kept up to date as part of the care planning process. Within the care plans and daily recording there was evidence that health needs of residents were being met. We saw that referrals were being made appropriately to health professionals such as GPs and district nurses. On the day of our visit a GP was visiting one resident at the request of the Registered Manager. We also received telephone feedback from one of the district nurses who visits the home. She told us that the home referred people appropriately for nursing needs. We also saw examples within the records that chiropody, dental and hearing needs were attended to. Avonwood Manor DS0000043057.V364521.R02.S.doc Version 5.2 Page 13 On the day of our visit we observed interaction between staff and residents. The staff were seen to treat residents with respect. The relatives we spoke with said that they were happy with the levels of care provided in the home and that when they visited their relatives, they looked well-groomed with attention paid to their clothing and personal appearance. Two returned comment cards from relatives said that they were happy with the way the home looked after residents. At the last inspection in July 2007 a requirement was made concerning the medication administration records, as there were some gaps within the recording of medicines administered to residents. At this inspection we looked at the medication administration records for one section of the home. At the front of each recording sheet there was a photograph of the person so that they can be easily identified, and a sample of staff signatures of those staff trained in safe administration of medication. We found that there were no gaps in the administration records. We do recommend however, that where hand entries have to be made to the medication administration records these are checked by a second member of staff who then signs that the entries have been made being correctly. We looked within the medication trolley serving this section of the home. We saw that medications were being stored safely and in accordance with good standards. The trolley is kept locked with the senior member of staff on duty holding the key and being responsible for the medication cabinet. The home was found to have a controlled drugs cabinet that meets the amendments to the Care Home Regulations 2007. When we toured the premises we found a cream prescribed to one resident in the bedroom of another resident. It could not be established how this had come to be in the resident’s room. It was agreed and recommended that the home carry out an audit of the medication cabinet to ensure that no surplus or out of date medications are being stored in the cabinet. Avonwood Manor DS0000043057.V364521.R02.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from the home meeting their individual needs and from recreational and stimulation being provided. Visitors are made welcome and a good standard of food is provided. EVIDENCE: When residents are admitted to the home, relatives are requested to submit a personal life history to assist in meeting the person’s social, cultural, religious and recreational needs. We saw that a record was kept of all group and individual activities undertaken with residents. We learned through discussions with the managers that there are plans to employ a second activities coordinator, as at present the activities coordinator is responsible for providing activities in both sections of the home. One relative commented that they would like to see more activities for residents. Avonwood Manor DS0000043057.V364521.R02.S.doc Version 5.2 Page 15 It is recommended that the home carry through the plan to recruit a second activities co-ordinator. On the day of our visit an entertainer was singing with residents in the conservatory and we were told that a member of the local church was visiting the home later in the day. One relative told us that the hairdresser visits regularly. Relatives we spoke to and returned comment cards informed that visitors are made welcome at the home. Concerning one resident with whom the home had had difficulties engaging in personal care needs, we discussed the balance between the right of the person to exercise choice and control over their lives and the home’s duty of care. The manager was aware of the impact and expectations placed upon them under the Mental Capacity Act 2005. One returned comment card from a care manager said that the home worked well with relatives and tried to accommodate their wishes. As reported at the last inspection a residents’ and relatives’ meeting is held every three months. At these meetings issues can be discussed and relatives and residents have an input into how the home is managed. Menus were seen informing of the meals for the day ahead. We sat in the dining-room during lunch and saw the food provided was a good standard and adequate portions provided. We saw that those residents whose care plan informed that they required assistance with eating received assistance from the staff. Records are maintained of food provided to residents and these provide detailed account of what each resident had eaten. We saw records for one resident where the care plan informed that staff must maintain fluid and food monitoring chance and that these were in place. The three sets of relatives we spoke with all informed that they thought the food was of a reasonable standard. One comment card also made favourable comments about the food. Avonwood Manor DS0000043057.V364521.R02.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from a well-publicised complaints procedure being in place and through staff at the home being trained in adult protection. EVIDENCE: The complaints procedure for the home is displayed in the main reception area and is also detailed with the Service User Guide and the Terms and Conditions of Residence. The procedure in the reception area displayed old contact details for the Commission. It was agreed that contact details would be amended and the manager informed us the day after the inspection that the correct details are now displayed. We saw the complaints log for the home. One complaint has been made to the management since the time of the last inspection in July 2007 to which a response had been made. Due to the mental frailty of the residents, they largely rely upon relatives to make complaints on their behalf. Through the staff training records we saw that all the staff receive training in the protection of vulnerable adults as part of their induction training and Avonwood Manor DS0000043057.V364521.R02.S.doc Version 5.2 Page 17 that they are also given further training at a later date through an external trainer. We spoke with two members of staff who told us that they had received training in adult protection. The home has copies of policies and procedures relating to adult protection that link to local safeguarding arrangements. Earlier in the year there was one adult protection alert where a staff member had not acted in line with the home’s policies and procedures. Mrs Phillips told us that she had taken steps to remind all staff of procedures to ensure that referrals are made speedily and appropriately where there were safeguarding issues. A returned comment card from a care manager informed that the home was good at keeping up to date with issues and adult protection guidance. They informed that they had been able to work well with the home in investigating any concerns. Avonwood Manor DS0000043057.V364521.R02.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents benefit from a well-maintained, clean environment. The proposed changes to the environment and action to make stairs safer will improve the home. EVIDENCE: The home is located in a quiet residential area close to the amenities of Westbourne. The home has car parking at the front of the building for staff and visitors. The regional manager updated us on planned changes to the premises. Work has already commenced on the loft conversion to create space for staff changing rooms, a staff locker room and staff room that can be used Avonwood Manor DS0000043057.V364521.R02.S.doc Version 5.2 Page 19 for training. There are also plans to make a more welcoming reception area and to move the office into the main building. This will be followed up at future inspections. At the inspection in July 2007 it had been reported that there had been a serious accident where a resident had fallen on one of the stairwells and since that time, there has been a second accident involving a resident on another stairwell within the home. As part of the inspection, a tour of the premises was made with the manager. It was agreed that risk assessments of the building would be updated with particular reference to the dangers posed by the stairs. The day after the inspection the home submitted an updated risk assessment with an action plan for the removal of mirrors on the stairwells, positioning of more hand rails on the stairwells and the decommissioning of one set of stairs in Nelson unit, subject to approval by the Fire and Rescue service. A requirement was made that this action be followed through. On the day of visit the home was found to be clean, in good decorative order and furniture and fittings in a good state of repair. Generally there were no unpleasant odours. Two comment cards informed that generally they found the home to be looking ‘nice and clean’. All of the radiators in the home have been covered to protect residents from burns and thermostatic mixer valves have been fitted to the hot water outlets of baths and showers to protect residents from scalding water. The home has a dedicated laundry room sited away from the two main buildings and is equipped with four commercial washing machines and three commercial driers. Two laundry staff are employed at the home. The laundry room has a washable floor and washable wall surfaces. Hand washing facilities are provided. Staff are provided with protective clothing and gloves. In the interests of infection control, alcohol gels are supplied to the staff and they receive training in infection control measures. The home has a sluice for the washing of commodes. Avonwood Manor DS0000043057.V364521.R02.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. 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 this service. Recent staff turnover has caused some difficulties in providing continuity of care to residents and proposed increases in staffing will benefit residents. Some improvements could be made in staff recruitment to ensure that residents are in ‘safe hands’. EVIDENCE: We were told that the home provides the same staffing levels as at the time of the last inspection with seven care staff on duty between 8am and 2pm, six staff between 2pm and 8pm and four staff on awake night duty between 8pm and 8am. We saw duty rosters in the manager’s office that reflected the above staffing. We were told that over the last few months there has been significant staff turnover and that the home has had to rely on the use of agency staff. We were told the adverts had been put out in order to recruit to the vacant posts. We were also told that there are plans to increase the staffing levels during the daytime to provide four carers and one senior within each section of the home. This will be followed up at future inspections. Concerning agency staff members, Mrs Phillips informed Avonwood Manor DS0000043057.V364521.R02.S.doc Version 5.2 Page 21 that she checks that agency staff members have an up-to-date Criminal Record Bureau check (CRB) and that she sees this before the staff are allowed to work in the home. To satisfy regulations, it is required that the home receives a letter from the agency to confirm that satisfactory recruitment checks of Scheduled 2 of the Regulations have been undertaken, before a member of staff can work within the care home. We looked at the recruitment records for staff employed since the last key inspection. These were found to be in order with the exception that gaps in the employment records for one member of staff had not been explained within the application form. It is recommended that where staff do not provide this information on their application form, this is followed up as part of the interview process. At the last inspection it was recommended that the staff application form be changed to request information in line with changes to the regulations. We saw at this inspection that changes to the application form had been made as recommended. We looked at the recruitment records for two members of staff who had been recruited to the home since the last inspection. We saw that new staff receive induction training that meets the standards set by Skills for Care. All staff are provided with core training in health and safety, first aid, moving and handling, principles of care, fire safety, infection control and adult protection. Staff also receive training in the care of people with dementia. This was discussed with the regional manager who informed that the organisation is looking to provide a better standard of training concerning dementia. This will be followed up future inspections. It is recommended that staff receive further training in the mental capacity 2005. Due to the high turnover of staff over recent months, the home falls well below the 50 guideline of staff being trained to the standard of NVQ level 2 or above. Currently there is one member of staff with NVQ level 2 and one with NVQ level 3. The home also employs four overseas workers with nursing qualifications. It was agreed that the registered manager would check the equivalence of these nursing qualifications, as they may be equivalent to NVQ level 3. It is recommended that the home develop a training schedule to ensure that 50 of the staff team is trying to NVQ level 2 or above. Avonwood Manor DS0000043057.V364521.R02.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31 33 35 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed and run in the interests of the residents. EVIDENCE: Mrs Phillips told us that she was still completing the Registered Managers award and that was her intention to still complete NVQ level 4 and that she is supported by the organisation. Avonwood Manor DS0000043057.V364521.R02.S.doc Version 5.2 Page 23 A new deputy manager has been appointed and is due to start work in July at the home. Issues identified during the inspection were acted upon immediately, demonstrating a commitment to improving standards in the home. Visits and reports by senior representatives of the organisation are taking place as required and Regulations 37 notices that inform the Commission of any deaths, illnesses and other events within the home are being forwarded as required. At the last inspection it was recommended that the home develop a procedure in the event of resident being admitted to hospital under the mental health act 1983. This has yet to be put in place and the recommendation remains. Returned comment cards reflected that the home was well managed. Concerning staff recruitment, as reported in the staffing section there was one recruitment file where gaps in the person’s employment history had not been investigated. A recommendation was made that at interview such issues are investigated. In the case of agency staff, although the Registered Manager checks that the worker has an up to date criminal record bureau check, a letter should be sought from the agency that all recruitment checks have been carried out. Mrs Phillips informed that she does not look after any monies for any residents. Avonwood Manor DS0000043057.V364521.R02.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Avonwood Manor DS0000043057.V364521.R02.S.doc Version 5.2 Page 25 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. 1. Standard OP7 Regulation Schedule 3 (m) Requirement You are required to ensure that where care plans instruct staff to keep monitoring charts, these must be kept up to date as part of the care planning process. You are required to carry out the action plan for the removal of mirrors on the stairwells, positioning of more hand rails on the stairwells and the decommissioning of one set of stairs in Nelson unit, subject to approval by the Fire and Rescue service. You are required to ensure in the case of agency workers that you receive a letter from the agency to inform that all recruitment checks of Schedule 2 of the Regulations have been undertaken, before these staff can work within the care home. Timescale for action 10/06/08 2. OP19 13 (4) 10/06/08 3. OP29 10/06/08 Avonwood Manor DS0000043057.V364521.R02.S.doc Version 5.2 Page 26 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 OP28 OP30 Good Practice Recommendations It is recommended that the home continue working to achieve a ratio of 50 of staff trained to NVQ level 2. It is recommended that the home develop training for the staff concerning the Mental Capacity Act 2005. It is recommended that where hand entries have to be made to the medication administration records these are checked by a second member of staff who then signs that the entries have been made being correctly. It was agreed and recommended that the home carry out an audit of the medication cabinet to ensure that no surplus or out of date medications are being stored in the Cabinet. It is recommended that where staff do not provide this information this is followed up as part of the interview process. Recommended that the home develop a procedure in the event of resident being admitted to hospital under the mental health act 1983. This is yet to be actioned on the recommendation remains in place It is recommended that where staff do not provide full information on their application form, this is followed up as part of the interview process. 3. OP9 4. OP9 5. OP29 6. OP37 7. OP29 Avonwood Manor DS0000043057.V364521.R02.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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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