Care Home: Park Avenue Nursing Home

What the care home does well Everyone planning to move into the home has a detailed assessment of their care needs. This assessment is repeated at admission to the home and so people moving into the home and their families can be confidant that care needs can be properly met. The atmosphere at the home is calm and people living at the home seem happy and confident in their surroundings.There is a good level of staff training to make sure that they can care properly for people. Staff showed knowledge and understanding of the people they care for. Responses in staff surveys showed that they felt well trained and that they had `good team work`. Families and friends are made very welcome at the home and are also supported to maintain relationships as indicated in written comments to the home: `with your help I started to re-build my relationship with my father.........I thought that the difficulties encountered during his 30 year decline into dementia had wrecked the close bond between us forever. I was wrong` There is a plentiful supply of a variety of foods and hot or cold drinks for people throughout the day. Staff are proactive in encouraging residents to eat and drink. Other healthcare professionals are involved when necessary and general practitioners gave positive response in surveys: `individual care with respect for the individual` `respond appropriately to residents needs` There has been a change of manager since the last visit but the provider has made sure that the home has had enough support for stability and continuity to be maintained for the benefit of the people living at the home. What has improved since the last inspection? Since the last visit a new format of care records (Quest) has been introduced following an intensive staff training programme. The quality of information within the care records has improved greatly and shows a commitment to `person centred` care. If used fully staff will have access to detailed information about individual abilities as well as the support needed. The refurbishment of the environment was completed in August 2007 and has greatly improved the suitability of the facilities for people with dementia. The development of the service continues with work already underway to provide additional safe and accessible outside space. The new manager provides clear leadership to staff. She and her staff are committed to the continued development and improvement of the service. What the care home could do better: After a great deal of hard work by the provider and staff at the home over recent years, it is now operating at a good level. There are firm foundations in place and there is clear opportunity to develop the service into a truly specialist dementia unit. The manager needs to work with her staff in continuing to improve the activity provision and stimulation provided to people living at the home. The manager should work with her staff and make sure that training continues for all staff so that they fully implement the `person centred` approach to care for people living at the home. Recommendations appear at the end of the report. CARE HOMES FOR OLDER PEOPLE Park Avenue Nursing Home 8 Park Avenue Leeds Yorkshire LS8 2JH Lead Inspector Catherine Paling Key Unannounced Inspection 9th 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 Park Avenue Nursing Home DS0000001364.V357425.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Park Avenue Nursing Home DS0000001364.V357425.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Park Avenue Nursing Home Address 8 Park Avenue Leeds Yorkshire LS8 2JH 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) 0113 2655890 0113 2733084 www.bupa.co.uk BUPA Care Homes (GL) Ltd Vacant Care Home 53 Category(ies) of Dementia - over 65 years of age (53), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (53) Park Avenue Nursing Home DS0000001364.V357425.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: Dementia - Code DE(E) and Mental Disorder, excluding learning disability or dementia - Code MD(E) The maximum number of service users who can be accommodated is: 53 6th February 2007 2. Date of last inspection Brief Description of the Service: Park Avenue Nursing Home is a large converted building with 53 registered beds. However, recent refurbishment and improvements to the facilities together with a planned reduction in the number of shared rooms mean that currently no more that 45 people can be accommodated. Personal care with nursing is provided for older people with dementia or mental disorder. The home is situated in a pleasant residential part of Leeds near to Roundhay Park, overlooking Soldiers Field and close to local amenities. The home provides accommodation in single rooms with two shared rooms available. The majority of rooms have en-suite facilities. The main dining room and lounges are provided on the ground floor with additional lounge space on the first floor. There is an attractive enclosed courtyard area with a feature water fountain, which can be safely accessed by the people living at the home. Additional safe and accessible outside space will be available from summer 2008. There will be an access lift to the garden for wheelchair users. Information is available to prospective residents and their families in the form of a statement of purpose and brochure that contain details about the services and facilities provided at the home. The current charges range from £555 to £690 per week. There are additional charges for chiropody, hairdressing, newspapers and aromatherapy. This information was provided during the visit in January 2008. Park Avenue Nursing Home DS0000001364.V357425.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. This was an unannounced visit by one inspector who was at the home from 09.30 until 17.00 on 9th January 2008. The purpose of the inspection was to make sure the home was operating and being managed for the benefit and well being of the people who live there and in accordance with requirements. Before the inspection accumulated evidence about the home was reviewed. This included looking at any reported incidents, accidents and complaints. This information was used to plan the inspection visit. A number of documents were looked at during the visit and all areas of the home used by the people who lived there were visited. A good proportion of time was spent talking with the people at the home as well as with the manager and the staff. An Annual Quality Assurance Assessment (AQAA) had been completed by the home before the visit to provide additional information. This is a selfassessment of the service provided. Survey forms were sent out to the home before the inspection providing the opportunity for people to comment on the service, if they wish. Information provided in this way may be shared with the provider but the source will not be identified. A small number of surveys were returned from staff, relatives and healthcare professionals. Their comments are included in the report. What the service does well: Everyone planning to move into the home has a detailed assessment of their care needs. This assessment is repeated at admission to the home and so people moving into the home and their families can be confidant that care needs can be properly met. The atmosphere at the home is calm and people living at the home seem happy and confident in their surroundings. Park Avenue Nursing Home DS0000001364.V357425.R01.S.doc Version 5.2 Page 6 There is a good level of staff training to make sure that they can care properly for people. Staff showed knowledge and understanding of the people they care for. Responses in staff surveys showed that they felt well trained and that they had ‘good team work’. Families and friends are made very welcome at the home and are also supported to maintain relationships as indicated in written comments to the home: ‘with your help I started to re-build my relationship with my father………I thought that the difficulties encountered during his 30 year decline into dementia had wrecked the close bond between us forever. I was wrong’ There is a plentiful supply of a variety of foods and hot or cold drinks for people throughout the day. Staff are proactive in encouraging residents to eat and drink. Other healthcare professionals are involved when necessary and general practitioners gave positive response in surveys: ‘individual care with respect for the individual’ ‘respond appropriately to residents needs’ There has been a change of manager since the last visit but the provider has made sure that the home has had enough support for stability and continuity to be maintained for the benefit of the people living at the home. What has improved since the last inspection? Since the last visit a new format of care records (Quest) has been introduced following an intensive staff training programme. The quality of information within the care records has improved greatly and shows a commitment to ‘person centred’ care. If used fully staff will have access to detailed information about individual abilities as well as the support needed. The refurbishment of the environment was completed in August 2007 and has greatly improved the suitability of the facilities for people with dementia. The development of the service continues with work already underway to provide additional safe and accessible outside space. The new manager provides clear leadership to staff. She and her staff are committed to the continued development and improvement of the service. Park Avenue Nursing Home DS0000001364.V357425.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Park Avenue Nursing Home DS0000001364.V357425.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 Park Avenue Nursing Home DS0000001364.V357425.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. (Standard 6 does not apply to this service) People who use the service experience good quality outcomes in this area. All people have their needs assessed before they are admitted to the home. The written information available to people and their families gives them the information they need to decide if they want to move into the home. We have made this judgement using available evidence including a visit to this service. EVIDENCE: Information provide in the AQAA stated that: ‘All prospective residents undergo a pre-admission assessment to ensure the home can meet any identified need and the placement will be appropriate. We provide comprehensive written information for prospective clients’. Park Avenue Nursing Home DS0000001364.V357425.R01.S.doc Version 5.2 Page 10 The records of someone who had recently been admitted showed that this was the case. A detailed assessment was carried out before admission. A further detailed assessment was completed on admission to make sure that there were no changes in care needs that could be overlooked. Assessment information was very detailed covering all aspects of care with clear instruction about next of kin contact arrangements as well as reasons for admission, past history and detail of current medication. A scoring system is used to indicate the level of care required and the need for a detailed care plan to be produced to provide staff with information and instruction on care. This ‘scoring’ is repeated over time and demonstrates changes in dependency and care needs. There is a clear commitment to equality and diversity that has been developed by the introduction of the new ‘Quest’ documentation and a commitment to ‘the delivery of Person Centred Care’. Although there is reference to religious and cultural needs this was only by ‘yes/no’ responses. There was recognition by the manager that needed to be given more attention to encourage staff to recognise and address cultural and religious needs. This will be done through the further development of the new ‘Quest’ documentation, which is imminent, and continued staff supervision and training. Park Avenue Nursing Home DS0000001364.V357425.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 and 10. People who use the service experience good quality outcomes in this area. The information within records and the knowledge of the staff means that the physical and healthcare needs of people are being met. Staff respect the dignity and privacy of the people living at the home. People are protected by the safe medication practices in place at the home. We have made this judgement using available evidence including a visit to this service. EVIDENCE: It was stated in the AQAA that : ‘All residents have comprehensive personal care plans individual to their identified needs’. Park Avenue Nursing Home DS0000001364.V357425.R01.S.doc Version 5.2 Page 12 Since the last visit new care documentation (Quest) has been introduced by the provider and all staff involved in record keeping have had comprehensive training. The result is detailed and comprehensive records which provide more ‘person centred’ information about care. There are plans to include care staff in the daily records following training. The care records were comprehensive and included a high level of personal detail about care needs with clear information about individual abilities as well as the support needed from staff. There was also guidance for staff on how to approach people who, for example, might not always welcome intervention from staff. The care plans are written in partnership with the person involved and their family. During the visit one of the nurses was seen discussing the care needs of a recent admission to the home with a relative. The care plans are reviewed on a monthly basis. Comments in surveys showed that relatives have confidence in the staff: • ‘if needs be (they) contact me’ • ‘staff seem friendly and show kindness and concern for the residents’ There is a comprehensive range of risk assessments carried out for all the people living at the home on admission. These are reviewed on a regular basis and include the risk of skin damage and the identification of those at nutritional risk. There was clear evidence of the involvement of other healthcare professionals when needed, for example the general practitioner (GP) and the tissue viability nurse (TVN). Positive comments were received in surveys from GPs: • ‘individual care with respect for the individual’ • ‘respond appropriately to residents needs’ Care needs to be taken that the records are fully used by staff. For example, the TVN had written in one person’s records in December recommending that the specialist mattress in use needed servicing or changing as it appeared to be faulty. There was no evidence to suggest that any action had been taken and on the day of this visit the mattress was indicating a fault. Another person’s records noted chiropody was needed every six weeks. A September appointment had been recorded but nothing since then. In another case some of the language used in the daily record was Park Avenue Nursing Home DS0000001364.V357425.R01.S.doc Version 5.2 Page 13 inappropiate and suggested a lack of understanding of dementia. For example, it was recorded in one person’s file that they were ‘sent downstairs for activities but (was) brought back for misbehaving’. There is a system in place for the ongoing audit of the care records by the manager and this should ‘iron out’ any ommissions and inappropiate language as well as continuing to provide support to staff through the changes. It was stated in the AQAA that: ‘Privacy and Dignity feature highly in BUPA Care Homes customer service programme, Personal Best’. Throughout the visit staff were seen approaching people in a sensitive manner and with respect. The people living at the home spoke freely with staff and visitors to the home and seemed confident in their environment. The regional director for the company was at the home for a routine visit and people living at the home seemed comfortable and relaxed with him. All the nurses have update in medication administration every year and this was most recently completed at the end of 2007. The manager carries out regular audit to help identify and address any shortfalls. Park Avenue Nursing Home DS0000001364.V357425.R01.S.doc Version 5.2 Page 14 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 and 15. People who use the service experience good quality outcomes in this area. People are encouraged and supported to exercise some choice over their daily lives and overall are provided with a stimulating environment. A good and varied diet is provided with individual needs taken into account. We have made this judgement using available evidence including a visit to this service. EVIDENCE: It was stated in the AQAA that: ‘We have a structured activities programme tailored to the individual needs and preferences of our residents’. The new manager has been at the home since November 2007. She has experience of being an activities organiser in a care setting. She has already started to develop and implement plans to improve the day to day activities Park Avenue Nursing Home DS0000001364.V357425.R01.S.doc Version 5.2 Page 15 and stimulation for the people living at the home, working closely with the activiites organiser. Part of this is the development of a 12 month programme based around celebrations such as Easter, Mothers Day, birthdays and Saints Days. The intention is that people living at the home, their relatives and the staff will be clear about the plans. This means that people living at the home are given help in knowing the time of year and staff are given prompts to develop conversation whilst discussing plans for forthcoming events. It was identified at the last visit that staff need to use background information about people to more effectively direct activities to avoid boredom and provide a more stimulating environment. The new manager is committed to making this happen by the use of such initiatives. It was observed during this visit that, overall, staff were better at involving people in activiites. For example, one small group were occupied cutting fruit up to make ‘smoothies’ and one person was busy taking old photographs out of an album. There is a noticeboard for relatives where the weekly activity programme is displayed along with photographs of Christmas activities. Thank- you cards from relatives were also pinned on this board and comments were comlimentary about the care given to the people living at the home and the support given to families: • • ‘I admire the patience, care and repsect that you show towards the residents’ ‘with your help I started to re-build my relationship with my father………I thought that the difficulties encountered during his 30year decline into dementia had wrecked the close bond between us forever. I was wrong’ Visitors are welcomed at the home throughout the day and relative surveys provided positive comments around choice: • ‘unable to choose ……. But they do allow my mother to sleep in on a morning if she is tired’ Nourishing snacks and drinks are available freely throughout the day and people are encouraged to eat and drink. Problems had been experienced with heating and in response to this the manager had arranged for hot soup to be served in the middle of the afternoon. People had enjoyed this so much that it was now to be served three times a week. There is an overall improvement in the way staff respond to people at the home and this needs to be further developed so that staff are better equipped to deal effectively with the particular demands of this client group. Park Avenue Nursing Home DS0000001364.V357425.R01.S.doc Version 5.2 Page 16 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. People who use the service experience good quality outcomes in this area. People living at the home and their relatives have their concerns taken seriously and action is taken to resolve issues. People are protected from abuse by well trained staff. We have made this judgement using available evidence including a visit to this service. EVIDENCE: It was stated in the AQAA that: ‘We have a clearly defined company complaints policy with agreed timescales for managing complaints. The information that accompanies the policy is prominently displayed in the home. The policy includes a three tier framework including the home, the regional management team and the national Quality and Compliance department’. This was found to be the case and information was clearly displayed in the home. The manager completes monthly returns to head office of any complaints and compliments received. There have not been any complaints recently although three have been received at the home over the last twelve Park Avenue Nursing Home DS0000001364.V357425.R01.S.doc Version 5.2 Page 17 months all of which were resolved within the 28 day timescale. Comments by relatives in suveys indicated that people were aware of how to complain: • had no concerns so far • no cause to make any complaints being very happy with the care given to my husband by all members of staff • never had concerns The AQAA stated that: ‘BUPA Care Homes has robust policies for dealing with allegations of abuse or neglect. Staff can not only raise concern within the home they have access to senior staff outside the home’. The manager has had training regarding the Mental Capacity Act 2005 and plans to provide training to staff. The AQAA includes information about how improvements can be made with ongoing training and education for staff on the importance of reporting and responding to all concerns no matter how minor they might appear to be. Park Avenue Nursing Home DS0000001364.V357425.R01.S.doc Version 5.2 Page 18 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. People who use the service experience good quality outcomes in this area. People live in a suitable, pleasant and well maintained environment. We have made this judgement using available evidence including a visit to this service. EVIDENCE: Since the last visit there has been major refurbishment and redecoration of the home. This work was completed in August 2007 although some more work is planned to further improve the suitability of the environment for the client group. Park Avenue Nursing Home DS0000001364.V357425.R01.S.doc Version 5.2 Page 19 Better use has been made of the lounge and dining space on the ground floor and there has been provision of a smaller lounge on the first floor. Dedicated space has been provided for the hairdresser. The doors on communal toilets and bathrooms are all painted red to make these areas easier to identify. A large flat screen television has been provided in the biggest lounge. Suitable picture displays are in the lounges and along corridors and have been placed at a suitable height for the people living at the home so they can look at them. There has been a planned reduction in the number of shared rooms available and just two remain. The home has been awarded a capital grant by the local authority, which is being used to improve the outside space available to people living at the home. Work has already started on creating a safe grassed area with a patio to the rear of the home. Plans to also provide lift access to the garden have been temporarily shelved but there will be ramp access for those in wheelchairs. The outlook to the front of the home is also being improved. On the day of the visit there were problems with the heating system. People were being kept warm while work was carried out to resolve the problem. The heating was mended and working by lunchtime. It was noted that some doors did not close properly. The manager was told and said she would arrange for them to be checked but that she was aware of a problem with some of the hinges, which had been replaced. The laundry service is based at the nearby sister home. The AQAA indicates that all of the permanent staff working at the home have had infection control training. Park Avenue Nursing Home DS0000001364.V357425.R01.S.doc Version 5.2 Page 20 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 and 30. People who use the service experience good quality outcomes in this area. There are enough trained and competent staff to meet the needs of the people living at the home. We have made this judgement using available evidence including a visit to this service. EVIDENCE: The duty rotas showed that staffing levels have been maintained and that overall there are enough staff to meet the needs of people living at the home. Some comments were received back in surveys from staff and from relatives saying that sometimes they felt that there were not enough staff: • (need to) improve the staffing of the home so that better services could be given to the services users’ • (Need to) review the staffing levels (to see) if need additional staff • ‘sometimes’ - ‘enough staff to meet needs’ Park Avenue Nursing Home DS0000001364.V357425.R01.S.doc Version 5.2 Page 21 These comments were shared with the manager who said that she felt there were enough staff but that she was looking at extending the roles of some support workers to give additional support, for example, over mealtimes. Staff continue to be enthusiastic about the training they have had and further training planned for them. They all show a commitment to the continued development of the service and feel well supported by the new manager. Care staff continue to undertake their National Vocational Qualification in care at level 2 and the home has now achieved a level of 50 of care staff with this qualification. The organisation shows a commitment to their staff and the AQAA states that: ‘BUPA Care Homes has achieved Investors In People (IIP) accreditation’. Safe and comprehensive recruitment procedures are supported by ‘comprehensive Human Resource policies’. A sample of individual staff personel files showed robust recruitment practices. The new manager has plans to develop individual staff portfolios and is also working on the production of a training matrix to help her make sure that everyone has had the training they need to care properly for the people living at the home. Park Avenue Nursing Home DS0000001364.V357425.R01.S.doc Version 5.2 Page 22 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 and 38. People who use the service experience good quality outcomes in this area. The home is well managed and the manager is well able to discharge her responsibilities. She provides good leadership to the staff and ensures that people are protected and cared for appropriately. We have made this judgement using available evidence including a visit to this service. EVIDENCE: Park Avenue Nursing Home DS0000001364.V357425.R01.S.doc Version 5.2 Page 23 The current manager, Ms Diane Ward, has been in post since November 2007. She is an experienced Registered Mental Nurse (RMN) and has worked for the company for a number of years although this is her first managerial role. She is already undertaking the Registered Managers Award (RMA), which she hopes to complete in February 2008. She has yet to make application to us to be registered as manager and the process was explained to her during the visit. Ms Ward is enthusiastic about her role and clearly knowledgeable and has commitment to the care of people with dementia. The manager has met informally with relatives and plans to hold more a formal meeting in the near future. A meeting has already been held with staff and notes were available. As part of ongoing review and assessment of the service the company has developed an audit tool – Early Warning Audit Tool (EWAT). This tool is an extension of the existing audit tool used as part of the regular provider visits to the home, which are required under Regulation 26. The AQAA provided information of other systems in place to monitor the service provided. These included: • ‘Regular Health & Safety meetings with a standardised agenda giving staff the opportunity to communicate on Health and Safety issues. The minutes from these meetings go to the Regional Manager’. • ‘There are regional and national experts available within the company for advice and guidance if required’. • ‘BUPA Care Homes has a comprehensive suite of Policy and Procedure manuals that are regulalrly reviewed by experts and updated when required’. • ‘BUPA Care Homes has an annual customer satisfaction survey’. • ‘BUPA Care Homes has appointed a Director of Quality and Compliance and has developed a national Quality and Compliance team of experts.’’ Many of these systems are well established. The additon of the Quality and Compliance Directorate is a new development as part of the in-house quality assurance systems. Park Avenue Nursing Home DS0000001364.V357425.R01.S.doc Version 5.2 Page 24 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 3 Park Avenue Nursing Home DS0000001364.V357425.R01.S.doc Version 5.2 Page 25 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. 1 Refer to Standard OP7 Good Practice Recommendations The manager should continue to work with staff to make sure that they fully implement the ‘person centred’ approach to care and that care records consistently contain comprehensive detail of care. This is to make sure that care needs are not overlooked. The manager should continue to develop her plans for activity provision to make sure that people receive stimulation and are occupied. The manager should submit her application to the CSCI to be registered. This is to demonstrate her day to day accountability at the home. 2 3 OP12 OP31 Park Avenue Nursing Home DS0000001364.V357425.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Park Avenue Nursing Home DS0000001364.V357425.R01.S.doc Version 5.2 Page 27 - 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. 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