Inspection on 18/06/07 for Park Avenue Care Centre

This inspection was carried out on 18th June 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Park Avenue Care Centre 15/05/08

Park Avenue Care Centre 29/06/06

Park Avenue Care Centre 03/02/06

Park Avenue Care Centre 14/07/05

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 Park Avenue Care Centre 69 Park Avenue Bromley Kent BR1 4EW Lead Inspector Ms Pauline Lambe Unannounced Inspection 18th June 2007 09:30 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 Park Avenue Care Centre DS0000058005.V335216.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. Park Avenue Care Centre DS0000058005.V335216.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Park Avenue Care Centre Address Park Avenue Care Centre 69 Park Avenue Bromley Kent BR1 4EW 020 8466 5267 020 8466 5367 laura.smith@excelcareholdings.com 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) Park Avenue Healthcare Ltd Arlette Beebeejaun Care Home 51 Category(ies) of Dementia - over 65 years of age (33), Old age, registration, with number not falling within any other category (18) of places Park Avenue Care Centre DS0000058005.V335216.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 29th June 2006 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 small garden to the rear off-street parking to the front and side of the property. The fees ranged from £575.00 - £670.00. Residents paid privately for person items, hairdressing, newspapers and chiropody care. Park Avenue Care Centre DS0000058005.V335216.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors from the Commission undertook the site visit for this unannounced inspection on 18th June 2007 and one inspector completed this on 19th June 2007. The manager was in charge of the home and assisted with the inspection. The service had a key inspection on 29th June 2006 and a random inspection on 22nd February 2007. This unannounced inspection included talking to residents, relatives, management and staff and inspecting records. Satisfaction surveys were sent to a number of relatives and residents and comments received are included in the report. Positive feedback was received from relatives and others about the quality of service provided. What the service does well: What has improved since the last inspection? What they could do better: Staff must have the necessary skills and understating required to meet the specific needs of residents with dementia. Suitable and appropriate signs must be provided to help residents identify areas of the home such as toilets and bathrooms. To ensure foods are correctly stored in the unit kitchenettes the fridge on the middle floor must be serviced or replaced to ensure it runs at the appropriate temperature. Staff must be aware and fully understand the procedures to follow in the event of disclosure or suspicion of abuse. Adequate shelving must be provided to store linen and all call bells must be maintained in good working order. Suitably qualified staff must be provided on all shifts. Park Avenue Care Centre DS0000058005.V335216.R01.S.doc Version 5.2 Page 6 Staffing rosters must reflect the names and designations of the staff on duty for each unit at all times. A system must be in place to ensure injuries sustained by residents, which occur when receiving care or are unexplained are fully investigated and action taken to prevent a recurrence. Bedrails must not be used on resident’s beds when the use of these is not in the best interest of the resident. Also staff responsible for selecting, fitting, maintaining and checking bedrails must receive appropriate training. When a decision is made to use bedrails for a resident’s safety then these must be fitted to both sides of the bed. The report includes some recommendations for the provider to take into consideration when assessing how standards are to be met. 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. Park Avenue Care Centre DS0000058005.V335216.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Park Avenue Care Centre DS0000058005.V335216.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 3 and 4, standard 6 did not apply to the service. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Resident’s needs were assessed prior to admission. Some of the practices seen in the home did not show that there was an adequate understanding of the needs of people with dementia amongst staff. EVIDENCE: Resident’s needs were assessed prior to admission. Copies of pre-admission assessments were seen on the care records viewed. The manager said that if staff from the home could not complete a pre-admission assessment then the placing authority provided relevant information to enable the home to make a decision on the suitability of the placement. Staff received training on dementia care however based on observation it was evident that staff did not always understand the needs of people with dementia. For example at the beginning of an activity session staff did not tell the residents how long the session would take, without explanation staff left Park Avenue Care Centre DS0000058005.V335216.R01.S.doc Version 5.2 Page 9 the room and returned to continue the session. This happened on more than one occasion. At no point were residents told the session had ended. Some staff were observed challenging residents for example a resident said they did not have breakfast and staff immediately corrected this statement, which resulted in the resident becoming more agitated. Some of the records seen indicated a lack of understating of dementia, for example one care plan indicated that because a resident called out frequently they were an “attention seeker”. A resident told the inspector that staff helped them out of bed but had not taken them to the toilet. Two members of staff immediately corrected this statement in the presence of the resident. Requirement 1. The premises lacked signs suitable for people with dementia. All of the doors looked similar and there were no signs provided to help residents identify key areas such as toilets and bathrooms. All bedrooms had a photograph of the resident displayed on the wall by the door. Requirement 2. Park Avenue Care Centre DS0000058005.V335216.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7 – 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans indicated that resident’s health and care needs were met. Medicines were safely managed. Some concerns were noted in relation to how staff interacted and responded to residents. EVIDENCE: Four care files were viewed. Care documentation continued to improve. Care plans seen showed how assessed needs were to be met and were reviewed monthly. Care plans were more personalised and included reference to resident’s preferences. One area for improvement was in relation to wound care planning. For example a resident with a number of wounds had one care plan and one wound evaluation record. If one wound healed then staff would have to rewrite the entire care plan. There was no photograph of any of the wounds. Body maps were maintained to show the site of a wound or injury. Some of the body maps seen were difficult to interpret as they included a number of different dated entries. It was evident from the care plans viewed Park Avenue Care Centre DS0000058005.V335216.R01.S.doc Version 5.2 Page 11 that relatives had signed to show they agreed with them. Recommendation 1. There were records in files of visits from other professionals such the GP, community psychiatric nurse, chiropodist, dentist and optician. Residents said they could see a GP when needed. The management of medicines were assessed on the middle and top floor units and were found to be good. Records of receipt, administration and disposal of medicines were up to date and well maintained. Staff had monitored the temperature in the medication storage area and this was usually kept within recommended limits. The home had a contract with the supplying pharmacist to dispose of unwanted medicines. The drug fridge for the middle floor required defrosting. The controlled drug medicine cupboard was used to store items such as jewellery and money. There were three controlled drug record books in use, one of these was labelled ‘second floor’ but the others were not clearly labelled. Recommendation 2. All of the bedrooms were for single occupancy with en suite shower and toilet. Care plans seen included guidance on how to respect resident’s dignity. For example staff to ensure bedrooms doors were closed when giving care and to involve residents in choosing what to wear. Some staff were observed interacting appropriately with residents. See comments under standard 4 and requirement 1. Park Avenue Care Centre DS0000058005.V335216.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12 – 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Suitable and varied activities were provided though of late these were not regular. Residents were satisfied with the meals provided and with visiting arrangements. There was evidence to show that resident choice was promoted. EVIDENCE: The activity person was on long-term leave and the manager said she was in the process of appointing a new person to the role. Individual activity records were maintained for residents and records seen showed that activity provision was generally good but there were periods in recent months when activities were not provided regularly. Feedback from some relative surveys suggested more mental stimulation would be beneficial. Arrangements were made for external entertainers to visit the home, for example an opera singer, a country and western singer and a parish choir. Relatives seen said they were made to feel welcome when they visited and were kept informed about significant issues. Park Avenue Care Centre DS0000058005.V335216.R01.S.doc Version 5.2 Page 13 There was some evidence in the care plans seen that staff promoted resident choice. Some residents said they were able to choose where they spent their day, what they ate and what to wear. Relatives were asked to sign a form to give their consent for their relative to be cared for in a room with a ‘hard floor’. One relative had signed to say they did not give their consent for this to happen but would like to have carpet in the bedroom. However this request had not been complied with as the bedroom had vinyl flooring fitted. When this was discussed with the manager she said she was unaware of the relatives request and would look into it. A number of residents were unable to comment in any detail about personal preferences. Lunch was observed on the middle and top floor units. A choice of meal was offered and residents were supported to eat where necessary. Residents spoken with were satisfied with the food provided. Comments included “the food is very good, I get a choice”, “the food is smashing”, “the food is well cooked and tasty and I would call this a good meal” - pointing to the lunch and one resident said they would like mash potato less frequently. At mealtimes staff wore blue vinyl gloves. This seemed rather clinical and unnecessary providing staff practiced proper hand washing procedures and food safety guidance. Records for the fridge temperature in the kitchenette on the middle floor showed that these had been running at between 16 – 17C degrees for some time but no action had been taken to rectify the situation. Requirement 3. Park Avenue Care Centre DS0000058005.V335216.R01.S.doc Version 5.2 Page 14 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): Standards 16 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Satisfactory procedures were in place to manage complaints. Some staff were unaware of the procedure to follow if they suspected that abuse had taken place. EVIDENCE: A policy and procedure was provided in relation to the management of complaints. Since the last inspection four complaints had been made to the home. These had been investigated and responded to in writing. One complainant was not satisfied with the lack of support staff provided when they wanted to make a complaint. For example staff were reluctant to provide the complainant with a copy of the complaints procedure and details of senior management staff. This resulted in the complaint escalating unnecessarily and the complainant felt the response showed a lack of understanding of people with dementia. During this inspection copies of the complaints procedure were seen in resident bedrooms. Comment cards received from residents and relatives indicated they knew how to make a complaint. Twelve compliments had been made to staff about the service since the last inspection. The home had a safeguarding adults policy and procedure, which had not changed since the last inspection. Since the last inspection no adult protection referrals had been made to the local authority or the Commission. Most staff had attended training on safeguarding adults. However the training record Park Avenue Care Centre DS0000058005.V335216.R01.S.doc Version 5.2 Page 15 provided indicated that a high number of adaptation staff had not received this training. Some staff spoken with were aware of the need to report poor practice and allegations or suspicions of abuse to senior staff but others were not fully aware of their responsibility to protect residents. For example one carer did not seem to understand what abuse was, however it was difficult to assess if this was due to a language barrier. Other care staff indicated they would initially manage the situation themselves. Requirement 4. Park Avenue Care Centre DS0000058005.V335216.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 21, 23 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was maintained to a satisfactory standard and areas seen, with the exception of one bedroom, were clean, tidy and free of offensive odours. EVIDENCE: The premises were maintained to a satisfactory standard. Most of the relatives and residents said the home was kept clean and tidy and this was the situation on the day of the inspection. The call bell in room 19 was loose which meant it only worked intermittently. On the middle floor a duvet and some hoist slings were seen on the floor possibly due to not enough shelving. The repairs to the bathroom on the middle floor identified at the last inspection had been addressed. One bedroom on the second floor required more attention to hygiene, as the bed bumpers and the wall by the bed were dirty. Park Avenue Care Centre DS0000058005.V335216.R01.S.doc Version 5.2 Page 17 Bathrooms and toilets seen were suitable to meeting the needs of the residents but the use of signs to enable residents to identify these areas should be provided. Requirement 5. A number of bedrooms on the top and middle floors were viewed and were generally clean, tidy, odour free and personalised. Facilities such as hand washing and protective clothing were provided to enable staff to practice infection control. Park Avenue Care Centre DS0000058005.V335216.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27 – 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing rosters were difficult to assess however these did show that there was not always adequate trained staff on duty at night. Recruitment procedures were good and staff received training relevant to their roles. EVIDENCE: The staff team comprised of a full time manager, deputy manager, trained nurses, nurses completing adaptation programmes, care assistants, domestic and ancillary staff. Copies of the staff rosters were provided. It was not possible to identify from the duty roster whether the deputy manager was working on the units or undertaking management duties. It was also difficult to assess whether there staffing levels were adequate on each unit, as the duty rosters seen indicated that at times there were no staff on night duty on some units and insufficient care staff on some day shifts. When inspectors counted the number of staff on duty for the home as a whole staffing levels were adequate on day shifts but there were occasions when there were not enough trained staff on night duty. The difficulty in assessing staffing levels from the rosters had been discussed with the manager on previous inspections. One relative made the comment that “Monday to Friday the level of care is ok but tends to diminish at the weekends”. Requirement 6. Park Avenue Care Centre DS0000058005.V335216.R01.S.doc Version 5.2 Page 19 A high percentage of care staff employed in the home were overseas nurses completing a training course to enable them to register with the nursing & midwifery council in England. This group of staff worked for periods of between three to nine months and resulted in approximately a 50 turnover of care staff every twelve months. This level of staff turnover could impact on continuity of care for residents particularly residents suffering from dementia. One relative commented on the impact this had on residents. Recommendation 3. From the information provided in the pre-inspection questionnaire the home employed six permanent care assistants. Four of these had achieved NVQ level 2. As mentioned the remaining care staff were overseas nurses and had achieved care training above NVQ level 2. Three staff files were assessed and found to comply with regulation. It was noted that one member of staff had taken on a new role but had not completed a new application form or been interviewed. At the last key inspection it was noted that a number of staff were difficult to understand due to their poor command of the English language and this situation remained the same. This could make communication with residents difficult particularly those with sensory impairment or suffering from dementia. One relative raised this as a concern and said that they found it difficult to understand some staff and some residents must also have this difficulty. Another relative made the comment that “more staff from different cultures need to be employed”. The manager said that English language training had been provided however this was not reflected in the training records seen. Recommendation 4. Access to training for staff was good. Regular in-house training sessions were held. Training was provided both by staff in the home and external trainers. Records indicated that since the last inspection staff had attended training sessions such as food hygiene, first aid, safeguarding adults, health and safety and dementia care. Staff spoken with said they received training relevant to their work. Park Avenue Care Centre DS0000058005.V335216.R01.S.doc Version 5.2 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 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 36 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A registered manager was in post and systems in place to review the quality of the service provided. Staff supervision was not provided regularly. Attention was generally given to providing a safe environment however some concerns were noted in relation to accidents to residents and the use of bedrails. EVIDENCE: The manager was registered with the Commission and had been assessed as having the skills and experience needed to manage this service. Regular meetings were held between the manager and trained staff and less frequently with care staff and other staff disciplines. Park Avenue Care Centre DS0000058005.V335216.R01.S.doc Version 5.2 Page 21 There was a system in place to monitor the quality of the service provided. This included in-house audits on areas such as care plans, medication, health & safety and the kitchen. The manager said that satisfaction surveys were sent to residents and relatives annually to obtain feedback about the service. The Commission received a copy of the last satisfaction survey report dated September 2006. The report did not include an action plan to show how areas requiring improvement would be addressed or other plans to improve the service. Regulation 26 visits were undertaken regularly and reports on these were seen. Resident meetings were held on individual units but in view of the needs of the residents these meetings were not very informative from a resident perspective. Meetings took place with relatives on a one to one basis and the minutes seen showed that relatives were invited to discuss any issues they had and to agree the content of care plans. Recommendation 5. Management did not routinely hold personal allowance money for residents but would do this on request. With the exception of one resident the manager said that relatives ensured residents were provided with personal items such as personal clothing, toiletries, newspapers and hairdressing. The manager was advised to refer the resident who did not have this facility to social services for assessment. There was evidence seen of staff supervision. However this was not provided on a regular basis. Recommendation 6. A random selection of health and safety records were viewed which included fire safety, hoist and bath service, gas, electricity supply, lift and legionella testing. All certificates and service records were up to date. Bromley environmental health department inspected the kitchen in February 2007. Monthly in-house checks were completed for areas such as call bell and emergency light testing. Regular fires drills were held and at times to include both day and night staff and the response time recorded. Accident records were viewed and entries varied. Some were well written, some lacked adequate information about the event and a number indicated the accident was the resident’s fault. A number of records seen were for residents who sustained injuries when receiving care but there was no evidence to show that any action had been taken to investigate these and prevent a recurrence. The need to have a system in place to follow up unexplained injuries and injuries sustained by residents when receiving care had been raised at previous inspections. Requirement 7. Staff carried out an assessment to identify risks before fitting bedrails for residents. All of the files seen for residents using this equipment included a risk assessment. One assessment indicated that the resident may climb over the rails and there was no evidence to show whether staff had considered alternative ways of maintaining this persons safety. One of the residents assessed as needing bedrails had the rail fitted to only one side of the bed. The other side of the bed was placed against the wall and had ‘bumpers’ Park Avenue Care Centre DS0000058005.V335216.R01.S.doc Version 5.2 Page 22 provided, which were held in place with Velcro. This was not seen as adequate protection for the resident. When bedrail are used then these must be fitted to both sides of the bed. Also on this resident’s bed there were two different sized mattresses, the ordinary and a pressure relief mattress, neither of which fitted the bed base properly and therefore posed a further risk hazard. Concerns regarding the assessment for and the use of bedrails have been raised at previous inspections. Requirements 8 and 9. Park Avenue Care Centre DS0000058005.V335216.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 ENVIRONMENT CHOICE OF HOME Standard No Score 1 2 3 4 5 6 Standard No 19 20 21 22 23 24 25 26 Score X X 3 1 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X 3 X X 3 X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 2 Park Avenue Care Centre DS0000058005.V335216.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP4 Regulation 12 Requirement The Registered Person must ensure that staff have the necessary skills and understating required to meet the specific needs of residents with dementia. The Registered Person must ensure that suitable and appropriate signs are provided to help residents identify areas of the home such as toilets and bathrooms. The Registered Person must ensure food is stored correctly. The fridge in the kitchenette on the middle floor must be serviced or replaced to ensure food can be safely stored there. The Registered Person must ensure through training and supervision that staff are aware and fully understand the procedures to follow in the event of disclosure of abuse. The Registered Person must ensure that all areas of the home are kept clean. Adequate shelving must be provided to store linen. DS0000058005.V335216.R01.S.doc Timescale for action 30/07/07 2 OP4 23 30/07/07 3 OP15 16 30/07/07 4 OP18 18 30/07/07 5 OP19 23 30/07/07 Park Avenue Care Centre Version 5.2 Page 25 6 OP27 18 7 OP38 13 8 OP38 13 9 OP38 13 Call bells must be maintained in good working order. The Registered Person must ensure that suitable qualified staff are provided on all shifts. Staffing rosters kept must clearly show which unit staff worked on for all shifts. The Registered Person must ensure injuries sustained by residents which occur when receiving care or are unexplained are fully investigated and action taken to prevent a recurrence. The Registered Person must ensure that bedrails are not used on resident beds when the use of these is not in the best interest of the resident based on the risk assessment. (Timescale of 5/3/07 was not met) The Registered Person must ensure that staff responsible for selecting, fitting, maintaining and checking bedrails receives appropriate training. When a decision has been made to use bedrail for a resident safety then these must be fitted to both sides of the bed. 23/07/07 23/07/07 23/07/07 23/07/07 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 OP7 OP9 Good Practice Recommendations Separate care plans and body maps should be kept for wound and injuries. Controlled drug books should be clearly labelled for each unit, jewellery and money should not be stored in the medicine cupboard and the medicine fridges should be defrosted regularly. DS0000058005.V335216.R01.S.doc Version 5.2 Page 26 Park Avenue Care Centre 3 4 5 OP27 OP27 OP33 6 OP36 Serious consideration should be gives to reducing the number of adaptation staff employed. Attention should be given to assessing employee’s level of English to ensure every effort is made to enable residents suffering from dementia to be able to communicate. An action plan should be prepared based on the findings of the annual satisfaction audit to address any issues noted and to show how the service plans to implement improvements. A system should be in place to provide regular supervision for staff. Park Avenue Care Centre DS0000058005.V335216.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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. Extracts may not be used or reproduced without the express permission of CSCI Park Avenue Care Centre DS0000058005.V335216.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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