Care Home: Avondale Nursing Home

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What the care home does well The registered proprietors have a daily presence within the home, with one of the proprietors being the registered manager. They both work closely with the matron who has day to day responsibility of the residents. Staff retention is very good and many of the staff have worked at the home for a number of years. This is beneficial to the residents as the staff are very knowledgeable of the support they require. The home provides good quality care to the residents who live there. We saw good interaction between the staff and residents and support being offered in a dignified, friendly and respectful manner. Medication administration and record keeping is of a good standard with the safety of residents being a priority. The dietary needs of all the residents are monitored to ensure good nutrition and hydration. What has improved since the last inspection? Avondale Nursing Home DS0000025947.V375500.R01.S.doc Version 5.2 There have been a number of improvements since the last inspection. The service now employs a part time activities coordinator who in conjunction with residents has introduced a more varied activities programme. Redecoration and refurbishment of some bedrooms and the lounge area has taken place as well as the purchasing of specialist chairs and hoists. The manger ensures that there are sufficient numbers of staff on duty at all times. All staff files now have a photograph of the employee on the front of their file. End of life issues are being addressed and the home is providing palliative care to those residents who wish to remain at Avondale Nursing Home. What the care home could do better: There were no requirements or recommendations made at this inspection however the proprietors/manager are constantly looking at the service and at ways to improve the quality of life for people living at the home. Key inspection report CARE HOMES FOR OLDER PEOPLE Avondale Nursing Home 26 Snakes Lane West Woodford Green Essex IG8 0BS Lead Inspector Julie Legg Unannounced Inspection 15th September 2009 10:00 DS0000025947.V375500.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Avondale Nursing Home DS0000025947.V375500.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Avondale Nursing Home DS0000025947.V375500.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Avondale Nursing Home Address 26 Snakes Lane West Woodford Green Essex IG8 0BS 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) 0208 506 2194 0208 559 0251 avondale.nursing@virgin.net Mrs Inderjeet Kaur Ford Ms Elizabeth Ruth Polkinhorn Ms Elizabeth Ruth Polkinhorn Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Avondale Nursing Home DS0000025947.V375500.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home with nursing - Code N to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Old age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is: 20 11th September 2007 Date of last inspection Brief Description of the Service: Avondale Nursing Home is a 20-place care home with nursing for older people situated in a residential part of Woodford. The accommodation is comprised of a two storey detached house with purpose built extensions to the side and rear. There is car parking to the front of the house, a small patio area to one side, and a garden to the rear. There are two connecting lounges on the ground floor, along with a utility room, kitchen, staff office, and some bedrooms. The remaining bedrooms are on the upper floor, along with bathrooms and toilets. There are two double bedrooms, both of which have an en-suite toilet, and 16 single rooms, many of which also have an en-suite toilet. The home is privately owned and managed by two business partners. They employ a matron to oversee the day-to-day care of the service users. The Statement of Purpose and the Service User Guide are issued to every prospective service user and both of these documents are readily available. A copy of the most recent inspection report is also available and a resident or relative/representative could request a copy from the manager. The fees for the home are £590-£650. The proprietor/manager made this information available on 15th September 2009 Avondale Nursing Home DS0000025947.V375500.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 stars. This means that people who use this service experience good quality outcomes. This was an unannounced inspection that was undertaken by the lead inspector Mrs Julie Legg. It took place on 15th September 2009 between the hours of 10.00 and 16.30. The registered manager and the other proprietor as well as the matron were available throughout the inspection and all three were available for feedback at the end of the visit. The inspection process included information obtained from the Annual Quality Assurance Assessment (AQAA), regulation 37 notifications, a tour of the home and documentation that was viewed at the home. We also had discussions with residents, relatives and staff. We had a discussion with the staff and people using the service about how they wished to be referred to during the inspection and the report. They expressed a wish to be referred to as residents and this is reflected accordingly in this report. What the service does well: The registered proprietors have a daily presence within the home, with one of the proprietors being the registered manager. They both work closely with the matron who has day to day responsibility of the residents. Staff retention is very good and many of the staff have worked at the home for a number of years. This is beneficial to the residents as the staff are very knowledgeable of the support they require. The home provides good quality care to the residents who live there. We saw good interaction between the staff and residents and support being offered in a dignified, friendly and respectful manner. Medication administration and record keeping is of a good standard with the safety of residents being a priority. The dietary needs of all the residents are monitored to ensure good nutrition and hydration. What has improved since the last inspection? Avondale Nursing Home DS0000025947.V375500.R01.S.doc Version 5.2 Page 6 There have been a number of improvements since the last inspection. The service now employs a part time activities coordinator who in conjunction with residents has introduced a more varied activities programme. Redecoration and refurbishment of some bedrooms and the lounge area has taken place as well as the purchasing of specialist chairs and hoists. The manger ensures that there are sufficient numbers of staff on duty at all times. All staff files now have a photograph of the employee on the front of their file. End of life issues are being addressed and the home is providing palliative care to those residents who wish to remain at Avondale Nursing Home. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Avondale Nursing Home DS0000025947.V375500.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 Avondale Nursing Home DS0000025947.V375500.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 2,3 and 5 (standard 6 is not applicable) People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who may use the service and their relatives/representatives have the information they need to assist them to make an informed choice as to whether the home is right for them. EVIDENCE: Copies of the Statement of Purpose, Service User Guide and the last key inspection are available in the reception of the home. The service is in the process of revising their Statement of Purpose to include that the home can Avondale Nursing Home DS0000025947.V375500.R01.S.doc Version 5.2 Page 9 offer palliative care. The Service User Guide is informative and written in plain English. The home understands the importance of providing sufficient information to prospective residents and their families and every assistance is given to enable people to make a positive choice as to whether the home is right for them. There may be some exceptions to this in the event of an emergency situation. The assessment is carried out professionally and sensitively and involves the individual and their family relative/representative, if appropriate. Where an assessment has been undertaken through a local authority or primary care trust the service ensures that they receive at least a summary of the assessment and a copy of the care plan. Admissions to the home take place if the service is confident that staff have the skills, ability and qualifications to meet the needs of the prospective resident. Any specialist training to meet the assessed needs will be given to staff prior to the admission. New residents are given a contract or provided with a statement of terms and conditions. These set out in detail what is included in the fees, the role and responsibility of the service provider and the rights and obligations of the individual. Prospective residents and/or their relatives/representatives are encouraged to visit the home and talk to residents and staff about life at Avondale. The manager actively promotes opportunities for discussions and clarification. Avondale Nursing Home DS0000025947.V375500.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7,8,9,10 and 11 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The health and personal care of each resident are set out in individual care plans. The principles of respect, dignity and privacy are put into practice. EVIDENCE: We looked at four residents’ files and all had a comprehensive care plans. Two of these residents were recent admissions to the home. Where risks had been identified, assessments were in place for areas such as falls, use of bed rails, moving & handling, tissue viability and nutrition. Daily record charts are informative and person centred and this contributes to positive monthly reviews for each of the residents. Avondale Nursing Home DS0000025947.V375500.R01.S.doc Version 5.2 Page 11 Residents are receiving effective personal and healthcare support using a person centred approach. Residents told us “staff are very kind, “I have a bath every day” and “nothing is too much trouble”. Relatives were also complimentary, “I have nothing but good things to say about the home, she is very settled and the staff are really kind, “I am very happy with the care”. Personal support is flexible and is able to meet the changing needs of the individual resident. In discussion with some of the staff they demonstrated a good knowledge and understanding of the individual needs of the residents. We observed that at the beginning of the inspection (10.00 am), some of the residents were still in bed and others were having their breakfast. Bedroom and bathroom doors were closed while staff were assisting the residents with their personal care. Staff were seen to be interacting well with residents. Assistance was given in a kind and respectful manner with staff ensuring that the needs of the residents were being met Aids and equipment are provided to encourage maximum independence and all of the aids and equipment are maintained in good working order. The home has recently purchased three specialist chairs to meet the specific needs of individual residents. All of the residents’ files showed evidence of the involvement of the GP, chiropodist, optician, dentist where relevant. Referrals are also made to the tissue viability nurse, dietician and other health professionals where appropriate. We looked at the medication storage, administration, safekeeping and disposal of controlled drugs. The home has developed efficient medication policies and procedures and medication records were viewed and found to be in good order; the matron regularly undertakes medication audits. Only qualified nurses administer medication and all have received appropriate training. The home has recently purchased a new medication trolley. The home is now caring for residents who are terminally ill or dying and their wishes or where necessary those of the family are recorded and sensitively discussed during the development of a person centred plan of care. The home is using the Liverpool Care Pathway and is working closely with external professionals and specialists for advice and support to assist the resident, their family and the home’s staff. The manager and matron have both attended training in palliative care, as have some of the nurses and care staff. The manager and matron are also undertaking an NVQ in palliative care. Avondale Nursing Home DS0000025947.V375500.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,14 and 15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are able to make choices about their lifestyle and are supported to retain life skills. Residents are able to participate in activities that are varied and suited to their individual needs and preferences. EVIDENCE: The home continues to improve around the provision of activities; there is an activities co-ordinator in post for two days a week. We also observed care staff now being more involved in activities with the residents which included talking to residents, reading a magazine and sitting with them and joining in a sing along. Care plans contain information residents’ social and spiritual activities and there is also a record of activities that are undertaken. We spoke to the activities co-ordinator who is keen to look at different activities which have been suggested by the residents. Activities that are being undertaken include: Avondale Nursing Home DS0000025947.V375500.R01.S.doc Version 5.2 Page 13 keep fit, baking cakes, crossword puzzles, flower arranging, memory teasers, painting pots, sing-alongs and bingo. During the summer volunteers from the local church visited and assisted residents to pot up some summer plants and provided strawberries and cream teas. Once a month the home provides music and movement session as well as a musical entertainer. Some of the residents go out with their relatives. Festivals such as birthdays, Christmas, Easter, St George’s Day and Guy Fawkes are celebrated within the home. The home is going to be taking part in a study with Warwick Medical School and the Barts & London hospital looking at Older People’s Exercise in Residential & Nursing Accommodation (OPERA). The religious needs of the residents are also respected and met; the vicar from the local church visits once a month and another resident receives weekly Communion. Visiting times are flexible and visitors confirmed that they could visit at any time. Relatives said that they were always made to feel welcome and that they could see their loved ones in the lounge or the privacy of their bedrooms. The signing-in book showed that there are a steady stream of visitors to the home and the manager told us that they relatives are very supportive of the home. Residents’ care plans i9ndicate their preferred name and their wishes regarding their end of life. They are also encouraged to bring into the home some of their own personal possessions. Meal times are flexible and on the dya of the inspection we observed one of the residents having her breakfast at 10.00. Residents/relatives meetings are taking place and one of the suggestions from these meetings were that more activities needed to take place and this has been taken on board by the manager. Meals are mostly served in the lounge, though some of the residents take their meals in their bedrooms. The cook has worked at the home for a number of years and is knowledgeable of all of the residents’ likes and dislikes. All of the residents’ health and cultural dietary needs are being met. On the day of the inspection meals were seen to be balanced and nutritious and choices were given. Fresh fruit and snacks are available during the day. Some of the residents require assistance with eating their meals and was seen to be carried out in a caring and sensitive manner. The manager is currently looking at providing menus in a pictorial format; this will assist those residents with some cognitive impairment and for those whose first language is not English. Avondale Nursing Home DS0000025947.V375500.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use this service are able to express their concerns and have access to an effective complaints procedure and are protected from abuse. EVIDENCE: During the inspection process we looked at the complaints log and there were no complaints recorded. The Annual Quality Assurance Assessment (AQAA) also confirmed this information. We are satisfied that any complaints the home received would be listened to, taken seriously and acted upon. The complaints procedure is on the notice board in the hallway of the home and residents and relatives that were asked knew how to make a complaint and would do so if they were unhappy about any aspects of the home. The Commission has not received any complaints and the local authority has not investigated any safeguarding issues at the home. Families or representatives administer all of the residents’ finances. The home holds small amounts of money for hairdressing, chiropody and other small sundries. Avondale Nursing Home DS0000025947.V375500.R01.S.doc Version 5.2 Page 15 The manager has an open culture where individuals would feel safe and supported to share any concerns in relation to their protection and safety. Policies and procedures regarding safeguarding adults are available to staff and they are given clear guidance about what action they should be taking. Staff files were looked and there was evidence that staff have attended in adult abuse and other safeguarding issues. Web spoke to staff and they confirmed that they had attended ‘safeguarding adults’ training and knew what action to take if they had any concerns regarding the welfare of the residents. Avondale Nursing Home DS0000025947.V375500.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19,22,24 and 26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use this service live in a clean, safe, comfortable and wellmaintained environment EVIDENCE: A tour of the home was undertaken and found it to be clean and free from any offensive odours. Some residents and relatives told us that the home is always clean and generally free from any offensive odours. Staff were aware of the need to exercise good infection control and policies and procedures are in place. Avondale Nursing Home DS0000025947.V375500.R01.S.doc Version 5.2 Page 17 The well maintained environment provides specialist aids and equipment to meet the needs of the residents; the home have purchased new hoists during the past year. The lounge/dining room is pleasantly decorated and furnished. New carpets have been laid and three specialist armchairs have been purchased that meet the specific needs of the individual residents. Bedrooms that were seen have been personalised by the resident and this is encouraged by the service. Since the last inspection some of the bedrooms have been redecorated and refurbished with new furniture. Call alarms are in place in all of the bedrooms and these were seen to be in reach of those residents who wish to remain in their bedrooms. We were advised that a new ‘wireless’ call system has been ordered. The large garden areas were well maintained as were other external areas. Avondale Nursing Home DS0000025947.V375500.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27,28,29 and 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff in the home are trained, skilled and in sufficient numbers to support the people who use the service EVIDENCE: Staff rotas were examined and they correlated with the number of staff on duty. The staffing ratios support the needs activities and aspirations of the resident in a person centred way. The service has not used any agency workers instead they rely on their own ‘bank’ staff; this is to the benefit of the residents as this means they are being supported by staff who know them well. Staff retention is very good and no members staff have left the service in the past twelve months as confirmed by the Annual Quality Assurance Assessment (AQAA). The service has a well developed recruitment procedure and the recruitment of good quality carers is seen as integral to the delivery of a good service. All staff undergo an interview, reference checks, POVA and Criminal records Avondale Nursing Home DS0000025947.V375500.R01.S.doc Version 5.2 Page 19 Checks. Induction and ongoing training is provided and staff confirmed that this was the case as did the AQAA. More than 50 of the staff have achieved NVQ level 2 or above. All staff are given a copy of the staff handbook and have access to all of the policies and procedures of the service. Training is given a high priority; many of the staff have attended training in palliative care, and both the manager and matron are undertaking an NVQ in this subject. The managers and matron have undertaken training in the Mental Capacity Act and this training in conjunction with Deprivation of Liberty training is currently being rolled out to staff. The person within the local authority who has responsibility for both of these important areas has visited the home and spoken to staff. Staff meetings are used for consultation and training and staff are involved in the development of the service. Individual supervision sessions regularly take place and staff told us that they find them useful for their development. Minutes of these meetings are kept on file. Avondale Nursing Home DS0000025947.V375500.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards31,32,33,35 and 38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management and administration of the home is based on openness and respect, it has effective quality assurance systems that are implemented by a competent manager. EVIDENCE: The registered proprietors/manager are both registered nurses and have many years and substantial experience in managing a care home. Both spend a Avondale Nursing Home DS0000025947.V375500.R01.S.doc Version 5.2 Page 21 considerable amount of time at the home and are supported by a very experienced matron. All three of the managers have a very real understanding of the needs of the residents and the areas in which the home needs to improve and further develop. Comments from both the residents, relatives and health professional were complimentary of the management. The proprietors/manager are competent in delivering effective financial planning and budgetary control. The manager was able to demonstrate an awareness of current legislation and development and plans the service accordingly. The returned Annual Quality Assurance Assessment (AQAA) was clear and contained relevant information supported by a wide range of evidence during the inspection. There has benn an improved quality of life for the residents with a strong focus on equality and diversity issues and the promotion of human rights. The service has sound policies and procedures which are regularly reviewed and the manager ensures that the staff follow them. The home works to a clear health and safety policy and regular audits take place to ensure they are working. The manager and staff have a good understanding of risk assessment processes which is underpinned by promoting independence, choice nad autonomy. Maintenance records are up to date as evidenced through the AQAA and in discussion with the manager. We are also satisfied that the financial interests of the residents are safeguarded and that their best interests are protected by the administration record keeping. The service continues to inform us of incidents as required under Regulation 37 of the Care Home regulations 2001. Since the last inspection there have not been any safeguarding of vulnerable adults referrals to the local authority neither have there been any referrals under the deprivation of liberty safeguards. Avondale Nursing Home DS0000025947.V375500.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 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 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 3 X 3 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 3 3 X 3 X X 3 Avondale Nursing Home DS0000025947.V375500.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. 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. Refer to Standard Good Practice Recommendations Avondale Nursing Home DS0000025947.V375500.R01.S.doc Version 5.2 Page 24 Care Quality Commission London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. 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