Care Home: Avon Lee Lodge

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What the care home does well The home caters for low level care needs the assessment process helps to ensure that individuals needs can be met in the home. The comment cards showed that those responding appreciated the friendly staff. One person commented. "The home is very diligent about keeping the residents and their accommodation in a clean and hygienic condition."There was evidence that the home responded quickly to any health concerns and made appropriate referrals for community healthcare support. This was confirmed by residents. Relatives were also positive about the care the residents receive. "I have been surprised by the level of support and care which staff give." "I am relieved that my xxx is being well looked after." The home offers a choice of activities and people said there was no compulsion to join in. The home arranges for gentle exercise session from accredited trainers. People are able to use a games console helping to promote activity and mental stimulation. Several people followed their own religious beliefs with support from friends at local churches. Those seen during the visit appreciated the home`s food. Comment cards suggested that there was a lack of variety at the teatime meal. People found the home had a homely environment which was kept in a good state of cleanliness. The proposed extension will provide much needed facilities for the home. What has improved since the last inspection? The medication system had been revised recently a new internal audit system identified errors and appropriate action was then taken. The policy had been revised to allow people to manage their own medication subject to risk assessment. The dining room furniture had been replaced and redecorated. There were several tables each seating up to four people creating a more homely atmosphere. A wireless call alarm system had been installed. The call boxes were portable reducing the problems of training wires. There is also a pendant linked to the system which is used by residents wanting to walk into the village. What the care home could do better: The comment cards showed the largest cause of concern for the residents was the high turnover of staff and how it affected the continuity of care. Some of the comments included that people felt the staff lacked experience another said that sometimes there was poor coordination between shifts. Somepeople said they sometimes felt the staff were too busy and didn`t listen to what the residents had to say. The preadmission assessments and care plans contained no evidence of the involvement of the resident or their representative. There had been improvements in the recruitment process however in two files there was no evidence available at the time of the inspection that gaps in employment histories were considered at interview. The fire alarm system should be tested from a different call point each week to ensure all points operate correctly. Accident reports were completed and trends analysed however the completed forms did not provide a clear audit trail. CARE HOMES FOR OLDER PEOPLE Avon Lee Lodge Preston Lane Burton Christchurch Dorset BH23 7JU Lead Inspector Trevor Julian Key Unannounced Inspection 22nd January 2008 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 Avon Lee Lodge DS0000064926.V358310.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. Avon Lee Lodge DS0000064926.V358310.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Avon Lee Lodge Address Preston Lane Burton Christchurch Dorset BH23 7JU 01202 476736 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) lkennedy@avonleelodge.co.uk/ avonleelodge@abbeyhomes.com www.avonleelodge.co.uk Mr Leigh David Kennedy Mrs Tracy Kennedy Mrs Tracy Kennedy Care Home 13 Category(ies) of Old age, not falling within any other category registration, with number (13) of places Avon Lee Lodge DS0000064926.V358310.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th May 2007 Brief Description of the Service: Avon Lee Lodge is a small residential care home located in a rural setting on the edge of the New Forest. It is owned and managed by Mr and Mrs Kennedy, who live in an adjoining property. The home is registered with the Commission for Social Care Inspection to accommodate a maximum of 13 older people. The property is a converted vicarage with 12 bedrooms and a communal area. There are 5 bedrooms on the ground floor, 2 with en-suite W/C and hand washbasin. On the first floor are 7 bedrooms (one double), 5 with en-suite facilities including one full sized bath. A stair lift operates on the main staircase there is also an external fire escape. Outside the gardens are very well maintained and provide seating areas and a sun house. Plans were well advanced to extend the property to increase the number of places offered and to improve the communal facilities. Local shops and amenities are available close by and a bus service travels to Christchurch. At the time of the inspection, the fees ranged between £450.00 and £550.00 per week for personal care and accommodation. Additional charges were made for hairdressing, newspaper, private chiropody etc. See the following website for further guidance on fees and contracts: http:/www.csci.org.uk/about_csci/press_releases/better_advice_for_people_c hoos.aspx Avon Lee Lodge DS0000064926.V358310.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. The unannounced inspection took place on 22nd January 2008 between 09:30 and 17:50. The owners, Mr and Mrs Kennedy, took it in turn to be at the home during the visit. The purpose of the inspection was to monitor the home against National Minimum Standards and to monitor progress made with issues previously identified. There had been two random inspections carried out since the last key inspection. Both random visits focussed on medication and were carried out by the Commission’s pharmacist. Before the inspection, they had provided an Annual Quality Assurance Assessment (AQAA) giving general information on management of the home and the range of needs catered for. Residents and visitors were also asked to complete comment cards giving their views of the home. Replies were received from:• Residents 12 (most assisted by a member of staff) • Relatives 8 • Staff 4 • Doctors 2 During the visit, further information was gathered through discussion with residents, staff and owners, a tout of the premises and case tracking three people living at the home. What the service does well: The home caters for low level care needs the assessment process helps to ensure that individuals needs can be met in the home. The comment cards showed that those responding appreciated the friendly staff. One person commented. “The home is very diligent about keeping the residents and their accommodation in a clean and hygienic condition.” Avon Lee Lodge DS0000064926.V358310.R01.S.doc Version 5.2 Page 6 There was evidence that the home responded quickly to any health concerns and made appropriate referrals for community healthcare support. This was confirmed by residents. Relatives were also positive about the care the residents receive. “I have been surprised by the level of support and care which staff give.” “I am relieved that my xxx is being well looked after.” The home offers a choice of activities and people said there was no compulsion to join in. The home arranges for gentle exercise session from accredited trainers. People are able to use a games console helping to promote activity and mental stimulation. Several people followed their own religious beliefs with support from friends at local churches. Those seen during the visit appreciated the home’s food. Comment cards suggested that there was a lack of variety at the teatime meal. People found the home had a homely environment which was kept in a good state of cleanliness. The proposed extension will provide much needed facilities for the home. What has improved since the last inspection? What they could do better: The comment cards showed the largest cause of concern for the residents was the high turnover of staff and how it affected the continuity of care. Some of the comments included that people felt the staff lacked experience another said that sometimes there was poor coordination between shifts. Some Avon Lee Lodge DS0000064926.V358310.R01.S.doc Version 5.2 Page 7 people said they sometimes felt the staff were too busy and didn’t listen to what the residents had to say. The preadmission assessments and care plans contained no evidence of the involvement of the resident or their representative. There had been improvements in the recruitment process however in two files there was no evidence available at the time of the inspection that gaps in employment histories were considered at interview. The fire alarm system should be tested from a different call point each week to ensure all points operate correctly. Accident reports were completed and trends analysed however the completed forms did not provide a clear audit trail. 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. Avon Lee Lodge DS0000064926.V358310.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 Avon Lee Lodge DS0000064926.V358310.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): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s admission process helps to ensure that people’s care needs are fully identified before a placement is offered. EVIDENCE: Two of the people case tracked, were admitted since the last inspection. In both cases the documentation showed good levels of detail and they also used a prompt to seek information about individuals daily routines. The records showed who had been consulted but neither the resident or their representative had signed the document to confirm agreement. In one case the assessment was not dated and so could have been created after admission. People spoken with could not accurately recall the admission process and no issues were raised from the comment cards received. One visitor said she was Avon Lee Lodge DS0000064926.V358310.R01.S.doc Version 5.2 Page 10 The AQAA stated that prospective residents were given a handbook clearly outlining the services provided. Once a new resident arrives there is an induction completed to ensure that the new resident understands the workings of the home e.g. call alarm system, fire alarm and procedures. Avon Lee Lodge DS0000064926.V358310.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. The people living at Avon Lee Lodge have good access to community services allowing their health needs to be well met. People experienced a supportive and caring environment. EVIDENCE: The three care plans which were case tracked, showed regular reviews being completed. There was information about the needs of individual residents and there were falls charts and in one case had lead to an Occupational Health and subsequently a physiotherapist referral. Weight charts were maintained to ensure unexplained gains and loss were picked up promptly. None of the care plans were signed by the residents’ or their representative so there was no evidence of the residents’ involvement or agreement. There were photographs of the residents on their files for identification purposes. A hospital admission Avon Lee Lodge DS0000064926.V358310.R01.S.doc Version 5.2 Page 12 form was created for each person to ensure that the hospital had basic information about the resident. People said they were able to request a GP visit at any time. This was reflected in the comments from GPs. One comment card reported that their friend no longer wore a hearing aid and this had added to communication problems, Mr & Mrs Kennedy said that they continued to prompt and persuade the resident however the resident had a right to decline. People in the home said they were treated well and the staff friendly, staff knocked their doors when entering their rooms and they were not spoken to abruptly. During the inspection, a friendly and supportive atmosphere was observed between the residents, staff and visitors. Since the last inspection, Mrs Kennedy had introduced a comprehensive audit mechanism to identify medication errors. The system allowed errors to be quickly identified and corrected. One error had shown up a significant issue and the home had been able to take prompt and appropriate action. A brief check of the medication showed that items were well stored and correctly administered. The home used a monitored dosage system provided monthly from the pharmacy unused items were returned at the end of each four week cycle. The home did have some items of medication not supplied in the monitored dosage system, two items were checked, and both had a clear audit trail. In the case of one person’s records, there were handwritten amendments to the medication administration record, these alterations could result in transcription errors and lead to medication being incorrectly administered. All handwritten entries should be checked and signed as correct by a second person. The home’s medication policy had been updated allowing people to self medicate following a suitable risk assessment and review. Lockable storage was available in each room. Avon Lee Lodge DS0000064926.V358310.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. The home provides a variety of activities to meet the individual needs of residents. People are able to make choices about their daily lives allowing them to feel valued. EVIDENCE: The home organised some activities in the premises this included a visiting library service offering a range of formats including talking books preferred by one of the residents. Residents were able to join in with gentle physical and mental stimulation provided by an accredited trainer. The home also offers church services in-house including communion. One person has a one to one weekly visit from her church friend, while another resident visits her local chapel each week with support from family and friends. The home appeared in the local press having introduced several residents to an interactive games console and general computer skills. The games console was enjoyed by several residents helping with coordination, exercise and balance. Avon Lee Lodge DS0000064926.V358310.R01.S.doc Version 5.2 Page 14 Some people said they preferred to stay in their own rooms and there were comments received that some of the residents were not capable of joining in with the computer game. One person said she appreciated being able to swap photos by email with her overseas family. Others did comment that they felt there was often nothing to do in the home. Two people said they had the confidence to go out for walks in the area and enjoyed the freedom they also said they enjoyed the garden during warmer spells. Another person commented that there were seldom trips out from the home. Mr Kennedy said that he was looking to provide a “pool car” to take residents on trips and shopping. They were also looking to arrange a larger, group outing later in the year. One visitor said that financial management was discussed during the admission process. The AQAA stated that the home did not act as an agent for any of the residents, for those who could not manage their personal allowances Mr Kennedy invoiced the responsible person for additional expenditure e.g. hairdressing and chiropody. Each room was fitted with a small safe for the storage of valuables. In one file, there was an inventory of personal effects brought into the home for the resident. The record wasn’t signed or dated so could leave the owners open to challenge when the resident leaves the home. The home’s meat and fish was sourced from local suppliers, as were milk and vegetables. The staff monitor weight and nutritional intake the AQAA cited the case of a resident who routinely requested soup rather than a full meal and this had resulted in weight loss. The home made a referral to a nutritionist whose advice and techniques allowed the individual to regain the lost weight. Staff were aware and able to cater for a range of special diets. The comment cards showed good levels of satisfaction with the standard of food. At the time the comment card were being returned the long- standing cook had left and had been replaced and some people voiced concern that the standards might fall. These comments were not voiced during the inspection. Some people did comment that the evening meals lacked variation and were of a poorer standard than the main midday meal. Avon Lee Lodge DS0000064926.V358310.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 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents feel able to raise day-to-day concerns with the management. Staff training helps to ensure that allegations or signs of abuse are responded to appropriately. EVIDENCE: The home’s complaint procedure was displayed in the entrance hallway allowing residents and visitors to know how to raise concerns. The home maintained a record of complaints and the action taken. Residents said they liked to raise concerns with the proprietors. Another commented that they weren’t sure who to raise concerns with when the owners weren’t available. Four staff had been trained in responding to Adult Protection alerts by the local social services. Places were limited and there were plans to send others as more courses were run. The home also covers the topic in the induction and ongoing training programme. In discussion with two members of staff, both were aware of their responsibilities in responding to allegations or signs of abuse. Avon Lee Lodge DS0000064926.V358310.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 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides a comfortable and clean environment for the benefit of the residents. EVIDENCE: Mr & Mrs Kennedy had operated the home for two years and were increasingly aware of the limitations of the building. Plans had been approved to extend the property to provide an additional eight bedrooms along with communal and office facilities currently lacking. The home is maintained to a good standard and during the inspection the premises were warm and clean. The home is heated by unguarded radiators, Mr Kennedy ensures random checks are carried out to ensure that the surface temperature is maintained below 43°C above which scalding can occur. The home had one assisted bath and some Avon Lee Lodge DS0000064926.V358310.R01.S.doc Version 5.2 Page 17 rooms had a bath in their en suite. The assisted bath was on the first floor and residents said that they were assisted upstairs to have their weekly baths. The home has a stairlift. Mr Kennedy stated that the bath seat needed attention and that would be replaced during the building work. One resident said she preferred baths and took the opportunity when her daughter took her home. She said she thought the new extension would have a proper shower room, this was confirmed by Mr Kennedy. Since the last inspection the home had provided new dining tables and chairs creating a more homely atmosphere. There was a new cordless call alarm system allowing greater flexibility there was also a pendant alarm available for people going out for a walk. The comment cards were very positive about the standard of the premises with several commenting that about the cleanliness. Just one response stated the home was not kept clean. Another said that minor repairs were not carried out promptly. The AQAA stated that the home had carried out a Department of Health audit of the infection control procedures and was working to complete the outstanding issues. Avon Lee Lodge DS0000064926.V358310.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 adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels were appropriate to the needs of the residents. There was a significant number of new staff who were developing the skills, training and experience to meet the needs of the residents. The home’s recruitment practice did not fully protect the residents. EVIDENCE: Two care workers staffed the home during the day reducing to one person overnight with support provided by a sleep-in carer in the adjacent building. Along with the care staff the home employed a cook, an administrator and domestic staff. There had been a significant turnover of staff since the last inspection and this had affected the continuity of care for some of the residents. In the comment cards, several residents and visitors had expressed their concerns about the changes in personnel and the apparent lack of experienced carers. One person commented that, “I have been surprised by the level of support and care that the staff give.” Avon Lee Lodge DS0000064926.V358310.R01.S.doc Version 5.2 Page 19 Mr and Mrs Kennedy were aware of the issues caused by the staff turnover. They had lost 6 care staff in a short space of time and were confident that the situation would settle and improve for the residents. The home used a training matrix to monitor the training completed and nominated for the staff. People accessed training through the supervision process to ensure the staff have the training skills and competence. Staff felt the training offered was good. The home had improved its recruitment procedures and of the three files checked all had the required clearances before they started work. The files also contained references from previous employers and a signed application form. Two of the files did not contain full employment histories although these were later provided. Avon Lee Lodge DS0000064926.V358310.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 operated and managed by qualified and experienced individuals. The home consults with stakeholders to help run the service in the residents’ best interests. Systems in place help to protect residents from the risk of financial abuse within the home. Procedures are in place helping to protect the safety of residents and staff. Avon Lee Lodge DS0000064926.V358310.R01.S.doc Version 5.2 Page 21 EVIDENCE: Mr and Mrs Kennedy had operated this home for over two years and had previous experience operating a care service. They have the required qualifications to manage the home. Mrs Kennedy had recently returned from maternity leave and several people commented that they were pleased to see her back and that they expected standards to rise in the home. The home used anonymous surveys from residents and other stakeholders to obtain their views. The results were used to inform the owners were attention was needed. At the end of the summer the home received a concern from an external agency, the issues were examined and they were working to address the improvements identified. The home did not manage the finances for any of the residents. When additional expenditure was incurred for chiropody, newspapers, hairdressing etc. those not managing their own personal allowances had invoices raised to recover the costs. The home had introduced first aid and manual handling training for staff. There was a special lifting machine for emergency use when someone falls this helped both the resident and the staff on duty. Fire training was up to date. The fire safety systems and equipment were routinely checked and serviced by contractors, weekly test of the fire alarm system were not carried out in rotation and could result in some points not functioning in an emergency situation. The home used an appropriate accident recording system however the completed reports did not have an audit trail. Avon Lee Lodge DS0000064926.V358310.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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Avon Lee Lodge DS0000064926.V358310.R01.S.doc Version 5.2 Page 23 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. Standard Regulation Requirement Timescale for action 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 3 Refer to Standard OP3 OP7 OP29 Good Practice Recommendations The pre-admission assessment should be dated and identify who was involved in the assessment. The home should ensure that there is evidence of the residents’ involvement in drawing up the care plan. The registered person should ensure that where an application form has gaps in employment, those gaps should be explored at interview and the reasons recorded. The registered person should ensure that fire alarm points are tested weekly, in rotation, to ensure that each device functions correctly. The registered person should ensure that the completed accident reports have an audit trail. 4. OP38 5 OP38 Avon Lee Lodge DS0000064926.V358310.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection South West Regional Office Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Avon Lee Lodge DS0000064926.V358310.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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