Inspection on 14/07/05 for Park Avenue Care Centre

This inspection was carried out on 14th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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

Park Avenue Care Centre 15/05/08

Park Avenue Care Centre 18/06/07

Park Avenue Care Centre 29/06/06

Park Avenue Care Centre 03/02/06

Park Avenue Care Centre 24/01/05

Park Avenue Care Centre 19/10/04

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Park Avenue Care Centre 69 Park Avenue Bromley Kent BR1 4EW Lead Inspector Maria Kinson and Pauline Lambe Unannounced 14 July 2005 08:50 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Version 1.40 G51G01s58005ParkAvenue.v235019.5.7.2005stage4.doc Page 3 SERVICE INFORMATION Name of service Park Avenue Care Centre Address 69 Park Avenue Bromley Kent BR1 4EW Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8466 5267 Excelcare Holdings Vacant Care Home with Nursing 51 Category(ies) of DE(E) 33 registration, with number OP 18 of places Version 1.40 G51G01s58005ParkAvenue.v235019.5.7.2005stage4.doc Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 24th January 2005 Brief Description of the Service: Park Avenue Care Centre opened in April 2004 and is located in a residential area of Bromley. Accommodation and facilities are provided over four floors, with access by passenger lift. The basement houses various services, such as training room, hairdressing salon, kitchen and laundry. The remaining three floors accommodate service users, all in single bedrooms with en-suite facilities. The ground floor has 15 beds and the first floor 18 beds, both of these are for residents with dementia who need nursing care. The second floor has 18 beds for older people who need nursing care. The home has a samll garden to the rear of the property and some off-street parking to the front and side. Version 1.40 G51G01s58005ParkAvenue.v235019.5.7.2005stage4.doc Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was undertaken by two inspectors from the commission between 08.50am and 18.50pm. To complete the inspection a further visit lasting 2.5 hours was made to the home by one inspector on 29th July 2005. Since the last statutory inspection on 24th January 2005 an additional visit had taken place on 11th March 2005 jointly by the Commission and Bromley social services, in relation to an adult protection matter. Prior to the inspection 4 hours were spent reviewing the service file. This inspection included assessing requirements and recommendations from previous inspections and issues identified in the service file. The inspectors undertook a partial tour of the home concentrating on the ground and first floor units and laundry. Time was spent talking with residents, staff and visitors. A selection of care, medication, complaints and health and safety records were examined and comment cards were distributed to residents and relatives. What the service does well: What has improved since the last inspection? Efforts had been made to improve the quality of care planning. This improvement must continue to ensure care plans fully meet standards. It was evident that staff had made efforts to involve residents or relatives with preparing care plans. Version 1.40 G51G01s58005ParkAvenue.v235019.5.7.2005stage4.doc Page 6 The manager had started the process of formal staff supervision and again this needed further development to ensure all staff received regular supervision. The manager said the staff team was more stable and this helped to provide continuity of care. What they could do better: The manager acknowledged that further work was required to improve the some aspects of care in the home. The home has a Statement of Purpose and Service Users Guide but some of the information contained in these documents was out of date. The home assessed residents prior to admission but did not confirm in writing whether they were able to meet prospective residents needs. Care records had improved but some of the paperwork was not dated, named or signed. Care plans were not always updated to reflect resident’s current needs. This could result in staff using a variety of approaches when managing challenging behaviour and a lack of consistency when treating pressure sores or wounds. The management of medication in the home was poor. Prompt action must be taken to ensure that adequate systems are in place to manage medication safely. Some activities and entertainment were taking place but some residents said that they felt bored and there was little evidence of regular activities taking place in the home. The food provided was not always suitable for residents with dementia and some additional items such as napkins and condiments would provide more choice for residents. A record of all complaints received in the home was maintained but the outcome was not always clear and there was no evidence that any action had been taken to address concerns. Overall the environment was good but additional fans or cooling units are required to make the temperature more comfortable for residents and staff and prompt action must be taken to ensure that the windows on the upper floors do not present unnecessary risks to residents with dementia. Some maintenance issues must be rectified and alternative storage space for the items currently kept in the bathrooms should be located. All residents should have access to a mirror in their bedroom or en suite area. This home has not had a registered manager since it opened in 2004. The current manager must submit an application for registration to the commission. Version 1.40 G51G01s58005ParkAvenue.v235019.5.7.2005stage4.doc Page 7 Further work is required to ensure that adequate support systems such as formal supervision are provided at regular intervals for staff. Individual training records should be maintained for all staff. Accident records were maintained but were not always completed in full. There was little evidence that senior staff were using the information obtained following an accident to reduce risks to residents. Staff were not able to test the hot water temperature prior to bathing residents, as there were no thermometers in the home. It was unclear from the records whether staff were responding promptly to fire drills. 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. G51G01s58005ParkAvenue.v235019.5.7.2005stage4.doc Version 1.40 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection G51G01s58005ParkAvenue.v235019.5.7.2005stage4.doc Version 1.40 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 3 and 4 Standard 6 does not apply to this home. The current Statement of Purpose and Service User Guide does not provide up to date information about the service for residents. Residents were assessed prior to admission but did not receive written confirmation that the home could meet their needs. EVIDENCE: The Service User Guide and Statement of Purpose were assessed prior to this inspection. The Statement of Purpose included all of the information listed in the Care Homes Regulations. The Service User Guide did not include information about the terms and conditions or a standard form of contract for services. Some of the information in both documents was out of date. There was evidence to show that residents were being assessed prior to admission. The pre-admission document was comprehensive covering both health and social needs. G51G01s58005ParkAvenue.v235019.5.7.2005stage4.doc Version 1.40 Page 10 There was no evidence to show that residents received written confirmation that the home could meet their assessed needs in respect of health and welfare. G51G01s58005ParkAvenue.v235019.5.7.2005stage4.doc Version 1.40 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 and 10 Written care plans were prepared for residents, but some plans did not provide sufficient information for staff to meet resident’s needs. The current management of medicines could pose a risk to resident’s safety. Resident’s privacy and dignity was respected. EVIDENCE: Four care plans were reviewed. All of the care plans included risk assessments such as moving and handling, nutrition and falls. Since the last inspection the manager said that she had spent time reviewing the care plan process with staff to improve the standard of record keeping in the home. The standard of care planning had improved but further improvements were required to show that resident’s assessed needs were being fully met. One care plan for a resident with challenging behaviour did not show how staff were to manage this issue and one care plan for a resident who had a pressure sore did not provide clear guidance about how the wound should be treated. Some of the care plans had not been signed or dated and some records did not include the resident’s name. Efforts had been made to review care plans regularly and to involve relatives. Residents had access to other relevant healthcare professionals when required. G51G01s58005ParkAvenue.v235019.5.7.2005stage4.doc Version 1.40 Page 12 The home had policies and procedures in relation to medication but these were not readily available to staff. The Commission Pharmacy inspector carried out an inspection on 6th December 2005. As a result of this inspection a requirement was made for the home to provide local procedures in relation to medication management. This requirement was not met. The medicine storage areas were very small and had limited space for the storage of the medical supplies and medicines. These areas were hot with temperatures of 32C degrees recorded in the first floor medicine store and no record of temperatures recorded on the ground floor. There was no evidence to suggest that the home had taken any action to address the previous requirement relating to this issue. Records were not kept for all medicines brought into the home, which meant that a full audit trail could not be completed. Records were kept for medicines returned to the Chemist. The manager was aware of the recent change to pharmacist’s contract in relation to the disposal of medicines. Administration of medication records were poor. Some medicines were not signed for at the time of administration, some medicines had been signed as given but were still in the packaging and staff did not record the amount of medication administered when a variable dose was prescribed. Five containers of topical medicines were seen in one resident’s bedroom. Some were not labelled and some had been dispensed some time ago. None of these preparations were included on the resident’s medication administration chart. A cylinder of oxygen was stored in the medicine area on the ground floor. There was no warning sign on the door to say oxygen was stored in the room, oxygen was not included on the homely remedy list and the nurse in charge said that none of the resident’s were currently prescribed oxygen. The nursing staff were unclear as to the provision of homely remedies, one member of staff gave the impression that the home had some homely remedies whilst another member of staff said the home did not stock homely remedies. A list of homely remedies was seen in the policy and procedure folder but this had not been signed by the GP and it included topical medicines. Some of the residents who spoke with the inspectors said staff treated them with respect. From observation staff interacted appropriately with residents. G51G01s58005ParkAvenue.v235019.5.7.2005stage4.doc Version 1.40 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 standard(s) 12, 13 and 15 The current provision of social activities does not meet resident’s needs. Visiting arrangements were satisfactory allowing residents to maintain regular contact with their family and friends. Residents were mostly satisfied with the food provided but some of the meals were difficult for residents with dementia to manage. This could result in frustration and a loss of independence. EVIDENCE: Some of the care plans seen did not include adequate information about resident’s interests and social background. The manager said that she had asked relatives to provide this information but this was not forthcoming. The care plans kept on the units had minimal information about how individual residents’ social needs were to be met. The home did not have an activities coordinator but the manager said the administrator was facilitating some activities in the period following lunch. Records of activities were kept separately and not with the resident’s files. The activity records seen provided little evidence that resident’s social needs were being met. A number of residents indicated that there was little to do during the day and said they “got bored”. A list of outside entertainers visiting the home during July was displayed. G51G01s58005ParkAvenue.v235019.5.7.2005stage4.doc Version 1.40 Page 14 The Statement of Purpose stated that the home had an open visiting policy. Visitors were seen throughout the day and said that they were made to feel welcome. The majority of residents who spoke to the inspectors indicated that the food was good. The inspection took place on a hot day and staff were observed encouraging residents to drink extra fluids throughout the day. Lunch and supper was observed on the first floor unit. Staff assisted and prompted residents to eat and a choice of food was provided. There were no condiments or napkins provided at either meal. Residents had sandwiches or salad for supper. Some of the residents found the salad difficult to manage. The manager said that summer and winter menus were provided but at the time of this inspection the winter menu was still in use and the lunch was considered to be a heavy meal in view of the hot weather. The inspectors were told that the summer menus were waiting final approval. G51G01s58005ParkAvenue.v235019.5.7.2005stage4.doc Version 1.40 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 standard(s) 16 and 18 Adequate systems were in place to manage complaints but records did not provide sufficient evidence that the company procedure was followed. This could damage the relationship that the home has established with residents and relatives. Staff displayed an awareness of the action that they should take to protect vulnerable adults. EVIDENCE: The home had policies and procedures on how to manage complaints and allegations or suspicions of abuse. The complaints procedure was included in the home’s Service User Guide and copies of this were seen in resident’s bedrooms. Records were kept of complaints made about the service but these did not include full details of the complaint, the action taken or the outcome. Since the last inspection two complaints were made to the provider and four to the Commission. The manager said both complaints made to the home were not finalised. The concerns raised with the commission included poor pressure area care, residents becoming dehydrated and poor infection control prevention. These areas of concern were assessed as part of this inspection. The majority of staff who spoke with the inspectors displayed a good understanding of adult protection issues and were familiar with the procedures for reporting allegations or suspicions of abuse. A number of staff had received recent training on this topic. G51G01s58005ParkAvenue.v235019.5.7.2005stage4.doc Version 1.40 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 - 26 The home was decorated to a high standard and was clean and comfortable. This provided a pleasant environment for residents. EVIDENCE: The home was registered by the commission in 2004 and was assessed as fit for purpose at this time. Overall the building was maintained to a satisfactory standard but some maintenance issues were brought to the manager’s attention. These included a broken toilet seat in room 11, a broken door lock, loose radiator grill and the door not closing fully in the first floor bathroom. The bathroom on the ground floor had items such as the vacuum cleaner and laundry bins. The ventilation in this bathroom did not appear to be working and the sluice door beside this bathroom would not close fully. The bathroom was therefore cluttered, warm and not very pleasant environment to bathe in. The inspection was carried out on a very hot day and the temperature on the units visited was uncomfortable. Some fans were provided and the manager said that she had ordered additional fans. G51G01s58005ParkAvenue.v235019.5.7.2005stage4.doc Version 1.40 Page 17 The home had adequate equipment in place to meet the needs of the current residents. Residents that spoke with the inspectors said they liked their rooms and they had adequate space for their personal belongings. Four rooms were inspected. All of the rooms were clean, appropriately furnished and nicely personalised. None of the bedrooms or en suite units had a mirror. Adequate protective clothing was provided for staff and hand washing facilities were provided in areas where waste was handled. The laundry area was well organised and equipped. The member of staff had a good understanding of the measures that she should take to prevent cross infection. G51G01s58005ParkAvenue.v235019.5.7.2005stage4.doc Version 1.40 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 The home had agreed a staffing level with the Commission at registration both in terms of numbers and skill mix. The way in which rotas were kept did not allow inspectors to accurately calculate the staffing levels maintained in the home. There was evidence of on-going training for staff but this standard was not assessed in full during this inspection. EVIDENCE: The staff team consisted of a full time manager, registered general and mental health trained nurses, care assistants and ancillary staff. One staff rota was prepared for the whole home. The prepared rota indicated which units the care staff were allocated to work on but it was not clear which unit the trained nurses were working on. When staff were moved to other units this information was not always recorded on the rota. This made it difficult to establish accurately who was on duty on each unit at any given time. The staffing levels agreed at the time of registering the home were the minimum levels based on anticipated resident dependency. The home must not be staffed below the agreed minimum levels however the registered person must ensure the home has enough staff on duty both with regard to numbers and skills to meet the assessed needs of the residents. In the inspectors view the dependency of residents in the dementia units was high. Therefore the registered person has been required to complete a dependency analysis of those residents and to send a copy to the Commission. The Commission will review staffing levels with the registered person based on the outcome of the dependency analysis. G51G01s58005ParkAvenue.v235019.5.7.2005stage4.doc Version 1.40 Page 19 There was evidence that some training had taken place since the last inspection, including dementia and moving handling. However it was not possible to establish the content of the courses or the credentials of the trainers. The attendance sheets for training sessions indicated that training was mainly provided by members of the staff team or the manager. There were no individual staff training records. This standard will be assessed in more detail at the next inspection. G51G01s58005ParkAvenue.v235019.5.7.2005stage4.doc Version 1.40 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 35, 36, 37 and 38 Since the home was registered several managers had been in post but none were registered with the Commission. It is essential that the home have a period of stable management so that the issues identified through this and other inspections that impact on resident care can be addressed. EVIDENCE: This home has not had a registered manager since it opened. The current manager was aware that she had to apply to the Commission for registration, but to date had not done this. The inspectors arranged for an application form to be sent to the manager to assist her with the application. The manager said that the home did not handle resident’s personal finances. This conflicted with the information provided in the Service User Guide. A recommendation to amend the Service User Guide was made in the last report and is repeated in this report. G51G01s58005ParkAvenue.v235019.5.7.2005stage4.doc Version 1.40 Page 21 Some staff said that supervision had commenced but it was not taking place regularly, other staff had not experienced supervision. There were no records of supervision. One page of the registration certificate was displayed in the reception area. The manager must ensure that both parts of the certificate are displayed and that action is taken to address the other issues identified in this report about record keeping. See comments under standards 7, 8, 9 and 38. Records of accidents occurring in the home were maintained. Some accident forms were not fully completed and there was no evidence to show that accidents that posed a potential future risk to the resident had been followed up. To ensure compliance with Data Protection accident forms should be removed from the accident book and stored securely. The accident books seen on the ground and first floors contained details of accidents that occurred on all of the units in the home. Using a separate accident book for each unit would make it easier for the manager to audit accidents. The top opening section of the windows on the upper floors of the home were not restricted and could pose a risk to resident safety. A selection of safety records were viewed. Records were generally well maintained but some records were not available on the day of the inspection. The manager was therefore required to forward the hoist and assisted bath service certificates and evidence of compliance with the water supply regulations to the commission. At the visit to the home on 29th July 2005 the engineer was in the home to service the hoists. Two hoists were serviced and on required a new part. The inspector was given written confirmation that the assisted baths were to be serviced on 1st August 2005. The manager was asked to confirm to the Commission when this had been done. Records of the fire alarm tests and fire drills were maintained. Records of fire drills did not include the staff response time and the fire alarm had not been tested weekly as indicated in the homes procedure. No thermometers were available for staff to check hot water temperatures prior to bathing a resident. G51G01s58005ParkAvenue.v235019.5.7.2005stage4.doc Version 1.40 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 x 3 2 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 2 COMPLAINTS AND PROTECTION 2 3 2 3 3 3 3 3 STAFFING Standard No Score 27 2 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 3 2 x x x 2 2 2 2 G51G01s58005ParkAvenue.v235019.5.7.2005stage4.doc Version 1.40 Page 23 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 1 and 35 Regulation 6 Requirement The Registered Person must keep under review and revise the Statement of Purpose and Service User Guide and notify the commission and residents of any such revision. The Registered Person must confirm in writing to the resident that having regard to the assessment the home can meet their needs in respect of health and welfare. The Registered Person must ensure residents’ care plans give accurate guidance about the actions required to meet their assessed health and welfare needs. (Timescale of 2nd November 2004 was not met) The Registered Person must ensure records are signed, dated, include the residents name and are kept up to date. The Registered Person must ensure that accurate records are maintained to reflect the treatment of pressure sores. (Timescale of 31st March 2005 was not met) The Registered Person must ensure that safe systems are in Version 1.40 Timescale for action 28 October 2005 2. 4 14 16 September 2005 3. 7 15 16 September 2005 4. 7 and 37 17 16 September 2005 16 September 2005 5. 8 12 6. 9 13 16 September Page 24 G51G01s58005ParkAvenue.v235019.5.7.2005stage4.doc 7. 12 16 8. 16 17 and 22 9. 19 23 10. 27 18 and 17 and schedule 4 place for the receipt, storage, administration and disposal of medicines. A record must be kept for all medicines brought into the home. Administration charts must be signed at the time of administration. Records must show the dosage administered when a variable dose is prescribed. Medication that is no longer prescribed for a resident must be disposed of. The temperature in the medicine storage areas must be monitored and action taken to ensure medicines are stored in accordance with manufacturers instructions. Local policies and procedures must be developed for the management of medication in the home. The Registered Person must ensure all residents have opportunities for stimulating leisure and recreational activities that suit their needs, preferences and capacities. (Timescale of 28th February 2005 not met) The Registered Person must ensure complaint records include the action and outcome of the investigation. The Registered Person must address all of the maintenance issues listed under the environmental standards. The Registered Person must ensure staff rotas are kept to accurately reflect the staff on duty in each unit at all times. In view of concers re staffing levels the registered person must complete a resident dependency analysis on the Version 1.40 2005 16 September 2005 16 September 2005 16 September 2005 16 September 2005 Page 25 G51G01s58005ParkAvenue.v235019.5.7.2005stage4.doc 11. 31 8 12. 36 18 13. 38 13 14. 38 13 dementia care units and send a copy of this to the Commission. The Registered Person must ensure an application to register the manager is submitted to the Commission by 02 September 2005. The Registered Person must ensure that staff working in the home receive regular formal supervision and records are kept of these sessions. The Registered Person must ensure future potential risks to residents identified following an accident, are as far as possible eliminated. The Registered Person must ensure that risks to the health or safety of residents are identified and so far as possible eliminated. This includes fitting restrictors to windows above ground level, providing hot water thermometers and ensuring staff response times to fire drills are recorded. 16 September 2005 28 November 2005 16 September 2005 16 September 2005 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 7, 8, 9 and 38. 15 Good Practice Recommendations The Registered Person should audit the management of care plans, medication and accidents at regular intervals and record her/his findings. The Registered Person should ensure tables are appropriately laid for meals. Menus should be changed seasonally. The meals provided should be suitable for people with dementia. The Registered Person should ensure that bathrooms are not used for storage and ventilation units are kept in working order. The Registered Person should ensure that all bedrooms or G51G01s58005ParkAvenue.v235019.5.7.2005stage4.doc Version 1.40 Page 26 3. 4. 21 24 5. 30 ensuite units include a mirror. The Registered Person should maintain individual training records for each member of staff so that compliance with regulation 18 can be verified. G51G01s58005ParkAvenue.v235019.5.7.2005stage4.doc Version 1.40 Page 27 Commission for Social Care Inspection River House 1 Maidstone Road Sidcup Kent DA14 5RH 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 G51G01s58005ParkAvenue.v235019.5.7.2005stage4.doc Version 1.40 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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