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Care Home: Avalon

  • 14 Pinewood Road Branksome Park Poole Dorset BH13 6JS
  • Tel: 01202761119
  • Fax: 01202761093

Avalon is registered with the Commission for Social Care Inspection (CSCI) to accommodate a maximum of 22 frail elderly service users with nursing needs. The home is owned by the Avalon Nursing Home (Dorset) Ltd, Mr A H Jaffer is the Responsible Individual. The home is currently without a Registered Manager but has an operations manager, Donna Neilson (the previous Registered Manager) in place and a newly appointed manager who will be applying for the Registered Manager`s position. The above current conditions of registration therefore are no longer applicable to the home. The home is situated in a residential area of Branksome Park. Accommodation is provided on the ground and first floor with two rooms on a mezzanine floor between. There are 8 single bedrooms with en-suite facilities and a further 6 singles without en-suite facilities. There are 4 double rooms 2 of which have en-suite facilities. The home has assisted bathing facilities on each floor and a passenger list for access between floors. On the ground floor a large conservatory has extended the communal space of lounge-dining room. There is a small and well-maintained garden surrounding the home, which is accessible to wheelchair users by ramps at the front door and the conservatory. Some recreational activities are organised. These include gentle exercise, board games and parties. Weekly fees range from £525 - £625 per week. The fee does not include hairdressing, chiropody or dry cleaning. See the following website for further guidance on fees and contracts www.oft.gov.uk (Value for Money and Fair Terms in Contracts). The home holds a copy of the most recent inspection report, which is available, on request.

  • Latitude: 50.710998535156
    Longitude: -1.9079999923706
  • Manager: Mrs Caroline Bacon
  • UK
  • Total Capacity: 22
  • Type: Care home with nursing
  • Provider: The Avalon Nursing Home (Dorset) Limited
  • Ownership: Private
  • Care Home ID: 2327
Residents Needs:
Old age, not falling within any other category

Latest Inspection

This is the latest available inspection report for this service, carried out on 18th September 2007. CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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.

For extracts, read the latest CQC inspection for Avalon.

What the care home does well What has improved since the last inspection? Care documentation has improved making it easier for staff to follow and any concerns regarding the health needs of residents are now promptly and appropriately followed up, with medical attention when necessary. Residents now have a monthly plan of activities so that they can decide what they want to do and when they want to participate in the programme on offer. The home was very fresh and clean and a daily walk around is completed by the manager each day, to ensure the standard is maintained and any housekeeping issues are dealt with quickly. Staff are now aware of the importance of using the hand washing facilities in the laundry to prevent cross infection and are now used appropriately. All care staff now have sufficient mandatory training, which includes health and safety, infection control and food hygiene. The home also has more than 50% of care staff that hold the NVQ award, ensuring that skilled and qualified carers care for residents at all times. The quality assurance monitoring system has improved and ensures that the home is run in the best interests of those living there. What the care home could do better: As a result of this inspection 1 requirement and 4 recommendations of good practice have been made.All admission documentation given to residents and relatives, which makes reference to the Commission for Social Care Inspection, should use the current name. The home should keep a copy of the letter sent to prospective residents confirming that it can meet their needs, within the individual`s file. Each care plan must set out in detail the care required to ensure that assessed needs in respect of the resident`s health and welfare are to be met. All care records should be completed in clear, legible writing and appropriately signed and dated so that they are relevant and can be read and used to support the delivery of care. It is recommended that the home keep a copy of individual`s NVQ certificates on each staff file, to provide evidence of the qualification. CARE HOMES FOR OLDER PEOPLE Avalon 14 Pinewood Road Branksome Park Poole Dorset BH13 6JS Lead Inspector Jo Pasker Key Unannounced Inspection 18th September & 10th October 2007 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 Avalon DS0000020425.V350408.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. Avalon DS0000020425.V350408.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Avalon Address 14 Pinewood Road Branksome Park Poole Dorset BH13 6JS 01202 761119 01202 761093 1avalon@btconnect.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) The Avalon Nursing Home (Dorset) Limited Vacant Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (22) of places Avalon DS0000020425.V350408.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Mrs Neilson must obtain an NVQ 4 in management by 01/04/08. Mrs Neilson must complete a training course in adult protection within six months and provide evidence of completion to the CSCI. 24th March 2003 Date of last inspection Brief Description of the Service: Avalon is registered with the Commission for Social Care Inspection (CSCI) to accommodate a maximum of 22 frail elderly service users with nursing needs. The home is owned by the Avalon Nursing Home (Dorset) Ltd, Mr A H Jaffer is the Responsible Individual. The home is currently without a Registered Manager but has an operations manager, Donna Neilson (the previous Registered Manager) in place and a newly appointed manager who will be applying for the Registered Manager’s position. The above current conditions of registration therefore are no longer applicable to the home. The home is situated in a residential area of Branksome Park. Accommodation is provided on the ground and first floor with two rooms on a mezzanine floor between. There are 8 single bedrooms with en-suite facilities and a further 6 singles without en-suite facilities. There are 4 double rooms 2 of which have en-suite facilities. The home has assisted bathing facilities on each floor and a passenger list for access between floors. On the ground floor a large conservatory has extended the communal space of lounge-dining room. There is a small and well-maintained garden surrounding the home, which is accessible to wheelchair users by ramps at the front door and the conservatory. Some recreational activities are organised. These include gentle exercise, board games and parties. Weekly fees range from £525 - £625 per week. The fee does not include hairdressing, chiropody or dry cleaning. See the following website for further guidance on fees and contracts www.oft.gov.uk (Value for Money and Fair Terms in Contracts). The home holds a copy of the most recent inspection report, which is available, on request. Avalon DS0000020425.V350408.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over the two days of the 18 September and 10 October 2007 and took approximately 8 hours. The purpose of the inspection was to assess all of the key standards and review the requirements and recommendations made in the last report. The newly appointed manager and the operations manager were both on hand to aid the inspection process and were very helpful throughout. Information for this report was obtained from discussion with the manager, operations manager, discussions with 5 residents and 2 members of staff on duty, a review of a variety of documentation including records provided to the Commission, care records, staff records, maintenance records, policies and procedures and a guided tour of the home. The annual quality assurance assessment (AQAA) sent before the inspection had also been completed and returned. A total of 5 comment cards from residents and relatives were also received and comments received in these and through discussion included: • • • • • “Always ensures mother is happy and has all needs catered for” “It is very clean and well staffed” “Polite and friendly, very happy home” “We are more than satisfied that Mum has all she needs and wants” “I am happy as my mother always remarks on how well she is cared for. It is peace of mind to see her well and settled”. What the service does well: A range of community health professionals support the home’s staff in looking after the residents. Activities and links with the local community are good and the home continues to have a varied calendar of events organised throughout the year. Residents are offered a good variety of meals and individual needs and requirements are well met. The complaints procedure can reassure residents that their views are important to the home and that any complaints they raise will be properly investigated. The home continues to protect those living there from abuse by ensuring the robust policies and procedures are in place and staff are aware of them. The home provides a safe and well-maintained environment for the residents, with a good standard of décor and comfort. Avalon DS0000020425.V350408.R01.S.doc Version 5.2 Page 6 The numbers and skill mix of staff are sufficient to meet the needs of residents. Staff receive adequate training in aspects of care work and other essential topics. Robust recruitment procedures are followed to ensure that residents are protected from the risk of unsuitable staff being employed. Management within the home is good ensuring that it is run in the best interests of the residents. Financial procedures within the home also ensure that residents’ interests are protected. The health and safety of the residents and staff are protected by the policies and procedures that the staff follow at Avalon. What has improved since the last inspection? What they could do better: As a result of this inspection 1 requirement and 4 recommendations of good practice have been made. Avalon DS0000020425.V350408.R01.S.doc Version 5.2 Page 7 All admission documentation given to residents and relatives, which makes reference to the Commission for Social Care Inspection, should use the current name. The home should keep a copy of the letter sent to prospective residents confirming that it can meet their needs, within the individual’s file. Each care plan must set out in detail the care required to ensure that assessed needs in respect of the residents health and welfare are to be met. All care records should be completed in clear, legible writing and appropriately signed and dated so that they are relevant and can be read and used to support the delivery of care. It is recommended that the home keep a copy of individual’s NVQ certificates on each staff file, to provide evidence of the qualification. 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. Avalon DS0000020425.V350408.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Avalon DS0000020425.V350408.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 & 3 (The home does not provide intermediate care so Standard 6 does not apply). Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and their families are given sufficient information to make an informed choice about whether to move to Avalon and new residents move into the home having had their needs assessed and been assured that these needs will be met. EVIDENCE: A comprehensive and up to date service user guide is available, which provides clear details of what a prospective resident and their relatives can expect from Avalon. This is also available in the form of an audio guide. The files for 2 residents who had recently moved into the home were reviewed and showed that the home has a good pre admission assessment in place. The manager is responsible for fully assessing the needs of the prospective resident and obtaining sufficient information to build a care plan upon, to ensure that Avalon DS0000020425.V350408.R01.S.doc Version 5.2 Page 10 the residents’ care needs can be met appropriately. The home confirms in writing to the resident and/or chosen representative that their needs can be met, although copies of these letters were stored electronically and no copies were seen in the residents’ files. Some of the documentation given to residents and their representatives had also not been updated with the Commission’s correct name. Avalon DS0000020425.V350408.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. 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. Generally, detailed care plans are in place, which provide staff with the information they need to meet residents’ needs but some improvements could be made regarding aspects of recording by staff. Medicine administration and handling is well managed and the health needs of the residents are well met with evidence of appropriate involvement from community health professionals; individuals are also treated with respect and dignity. EVIDENCE: The care records of 3 residents were reviewed and found to be comprehensive, up to date and relevant and were based on the findings of appropriate assessments. Files contained a variety of assessments including ones for falls, pressure area care, communication and nutrition. However, no care plan could be found for 1 resident whose pre admission assessment stated that they experienced seizures from epilepsy and some of the documentation viewed was not signed, dated or was illegible. All care plans were seen to be regularly Avalon DS0000020425.V350408.R01.S.doc Version 5.2 Page 12 reviewed though and there was some evidence of them being discussed with and signed by a resident’s representative. There was evidence of external healthcare professionals, such as GP’s and chiropodists, being involved in residents care and this was also observed in practice on the second day of the inspection, when a resident was identified as becoming acutely unwell and an ambulance was immediately called. Medicines were properly stored, being locked away and records were kept of the receipt, administration and disposal of medication and examination of these showed that all was well recorded and there was a clear audit trail available. An up to date list of staff specimen signatures and a homely remedies list was seen and all medicines checked were in date and appropriately dated when opened, where necessary. All the medicine administration records seen for each resident clearly stated whether there were any known allergies to medicines and with no gaps seen in recording. Residents and relatives spoken with were happy with the care they received and confirmed that staff treated them with respect and were supportive and kind. Comments included: • • • “Mother always says how happy she is and how well they look after her” “The nurses and carers, as far as I can tell and the ones I meet when visiting are mostly very good, kind and considerate” “Exceptionally caring to all patients needs”. Avalon DS0000020425.V350408.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. 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. There is a range of activities and social events planned by the home, which meet the residents’ social, recreational and religious needs and visits by their friends and relatives are welcomed by the home. Both relatives and staff members assist residents to make choices, enabling them to exercise control over their daily lives and the choice of meals ensure that residents receive a wholesome diet. EVIDENCE: A range of events and activities are organised by the activities co-ordinator and these are displayed on the notice board in the hall. They include: • • • • • Poems Exercise Music and singing Board games Trips out Avalon DS0000020425.V350408.R01.S.doc Version 5.2 Page 14 Outside entertainers are also popular and the monthly plan showed that there were 3 days that month where different musicians would be coming to the home. Good evidence was seen of individual residents’ interests and hobbies documented on activity profiles and also 1:1 sessions that had taken place. When asked ‘What does the home do well?’ on the resident’s and relative’s surveys, one of the responses was “activities” and it was acknowledged that the home does it‘s best to “...prevent boredom and encourage awareness”. Visiting is open and flexible and visitors are welcomed into the home and to participate in the homes’ events. Several visitors were spoken with during the inspection and confirmed that they were always made to feel welcome and that the home had “a homely, warm atmosphere”. The menus seen offered a good choice of food and individuals’ preferences are catered for. Residents appeared to enjoy their lunch and had the choice of eating in their room or in the communal dining room. It was observed that people were encouraged to be as independent as possible with plate guards and clothes protectors used appropriately, whilst others were given extra assistance as needed. Avalon DS0000020425.V350408.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. 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. The home has a good complaints system, which ensures that complaints are managed properly and residents and relatives can be sure that their concerns will be listened to and acted upon. Adult protection is appropriately addressed in staff training and policies and practice are in place, in order to safeguard residents from potential abuse and harm. EVIDENCE: The home has a good complaints policy and residents confirmed that they were confident to speak to staff if they had a problem. The Commission and the home have received no complaints since the last inspection. All residents and relatives asked in their surveys ‘Do you know how to make a complaint?’ responded ‘yes’ and when asked if the home had responded appropriately to the complaint, 2 relatives answered ‘always’ and 2 answered ‘usually’. The home has a policy and procedure to respond to suspicion or evidence of abuse or neglect. Staff confirmed that they receive training on the protection of vulnerable adults and through discussion it was apparent that they had a clear understanding of local procedures. All staff must read and sign that they have read a copy of the Department of Health’s guidance ‘No Secrets’. Since the last inspection there have been 2 adult protection referrals made and after investigation by the local authority, 1 was found to be unsubstantiated and the other partially substantiated. Avalon DS0000020425.V350408.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): 19 & 26 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 maintained, has a clear on going programme of maintenance and refurbishment and is clean and free from any offensive odours, ensuring that it provides a safe and pleasant place to live for residents. EVIDENCE: A tour of the premises found the home clean, fresh, in good order and providing a comfortable environment in which to live. The lounge/conservatory area is light and airy and has a ramp to allow wheelchair access to the gardens. The home has an on going programme of routine maintenance and refurbishment and the annual maintenance plan was seen which detailed how flooring was to be replaced in different areas, radiator covers to be changed and interior redecoration undertaken. New bedding, duvets and towels have also been provided in the last year and all rooms now have electric profiling beds. Avalon DS0000020425.V350408.R01.S.doc Version 5.2 Page 17 The laundry is shared with Ormonde and sited in an outbuilding between both homes with a dedicated laundry person who has undertaken infection control training. The laundry was viewed and was in good order, with all equipment in working order and adequate to cope with the washing needs of the residents. The hand washing facilities were accessible to staff and appeared to be regularly used and adequate supplies of gloves and aprons were seen around the home. Avalon DS0000020425.V350408.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): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sufficient levels of staff are employed to ensure that the needs of the residents are met and the home’s recruitment system ensures that residents are properly protected from the risks of potentially unsuitable staff being employed. Staff also receive comprehensive training, which enables them to be competent in their work. EVIDENCE: The staffing rotas for 2 weeks were viewed during the inspection and evidenced that sufficient levels of staff were employed to meet the needs of the residents. Residents and relatives spoken with commented that staff were usually available to help them when needed but there had been several changes in the staff team during the last year. The home has an ongoing training programme, which includes NVQ level 2 in care. The manager confirmed that at the time of inspection more than 50 of care staff held this award and other health care assistants had started work on the award. However certificates were not available to view in staff files. The files of 2 staff members were viewed and all relevant documentation was found to be present. Avalon DS0000020425.V350408.R01.S.doc Version 5.2 Page 19 Training files demonstrated that staff were receiving induction training and this was confirmed with staff spoken with during the inspection. All mandatory training was found to be up to date and recent staff training included: • • • • • • • Adult protection Food hygiene First aid Caring for confusion Infection control Fire safety Health and safety One respondent to the relative survey commented that, “The staff seem to have the right skills for mother’s needs and also for those in the home who are not so mobile”. Further information on available training can be accessed through the following websites: www.picbdp.co.uk www.skillsforcare.org.uk Avalon DS0000020425.V350408.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): 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 organised and the daily management and running of the home centres round the care of residents, with a new manager in post who will be applying to be registered with the Commission. Improved quality assurance systems are in place, to ensure that the home is run in the best interests of residents, their finances are well protected and the welfare of residents and staff are well promoted, ensuring that risks to health and safety are minimised. EVIDENCE: Since the last inspection the Registered Manager has resigned but to take up the post of operations manager for the group of homes that the Registered Provider, Mr Jaffer owns instead. At the time of inspection the new manager had only been in post for two weeks however she appeared very Avalon DS0000020425.V350408.R01.S.doc Version 5.2 Page 21 knowledgeable about the residents and their needs, was well supported by the operations manager and Mr Jaffer and the daily running of the home appeared well organised. She is also a Registered General Nurse and will be applying to the Commission to become the Registered Manager of the home. The home has made great improvements in their quality assurance systems since the last inspection and now has an annual development plan in place and carry out regular audits of the service. The home also submitted a completed AQAA prior to the inspection detailing how they currently meet Care Standards and how they plan to improve. Residents’, relatives’ and healthcare professionals’ opinions are sought by the home through the use of questionnaires and relative meetings held and there are plans to provide a newsletter covering both Avalon and Ormonde. A number of internal audits have been undertaken regularly and a daily walk around the home by the manager or senior registered nurse ensures that standards are maintained. Most residents choose not to deal with their own finances but they all had someone to act on their behalf. The home does not hold any money on behalf of residents. Records showed that all staff had undertaken fire safety training and that all fire checks were up to date. Accidents were recorded and appropriate action taken as necessary and all maintenance and safety certificates viewed were in date including, electrical testing, Legionella testing, gas and hoist maintenance. Avalon DS0000020425.V350408.R01.S.doc Version 5.2 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Avalon DS0000020425.V350408.R01.S.doc Version 5.2 Page 23 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 15(1) Requirement Each care plan must set out in detail the care required to ensure that assessed needs in respect of the residents health and welfare are to be met. Timescale for action 30/11/07 Avalon DS0000020425.V350408.R01.S.doc Version 5.2 Page 24 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 Refer to Standard OP1 Good Practice Recommendations All admission documentation given to residents and relatives, which makes reference to the Commission for Social Care Inspection, should use the current name. The home should keep a copy of the letter sent to prospective residents confirming that it can meet their needs, within the individual’s file. All care records should be completed in clear, legible writing and appropriately signed and dated so that they are relevant and can be read and used to support the delivery of care. It is recommended that the home keep a copy of individual’s NVQ certificates on each staff file, to provide evidence of the qualification. 2 OP3 3 OP7 4 OP28 Avalon DS0000020425.V350408.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF 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 Avalon DS0000020425.V350408.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!

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