Inspection on 15/08/05 for Avala Park

This inspection was carried out on 15th August 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Avala Park 16/09/09

Avala Park 12/06/08

Avala Park 13/06/07

Avala Park 13/11/06

Avala Park 10/01/06

Avala Park 20/10/04

Avala Park 21/06/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Avala Park Mile Road Widdrington, Morpeth Northumberland NE61 5QW Lead Inspector Deborah Haugh Unannounced 15 August 2005 9:30 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 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. Avala Park B53-B03 S553 Avala Park V239267 170505 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Avala Park Address Mile Road Widdrington Morpeth Northumberland NE61 5QW 01670 790019 01670 791203 avalapark@highfield-care.com Southern Cross Care Homes Limited Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Alison Martin CRH 35 Category(ies) of DE(E) - Dementia - Over 65 (11) registration, with number OP - Old Age (24) of places Avala Park B53-B03 S553 Avala Park V239267 170505 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: none Date of last inspection 20/10/2004 Brief Description of the Service: Avala Park is a purpose built two-storey home located in the rural village of Widdrington. Set back from the road the home has large gardens and ample car parking space.Local amenities and public transport are limited but include a small supermarket, public house, community centre and GP surgery.The home is registered to provide accommodation and personal care to 35 older people, 10 of whom have a dementia.The home is now owned by Southern Cross Care Homes Limited. Avala Park B53-B03 S553 Avala Park V239267 170505 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place on 15/8/05 at 9.30 am and lasted until 2.00 pm. At the time of this inspection the Registered Manager Mrs Alison Martin was on duty. There were 30 service users at the time of the visit and staffing levels were appropriate to meet the needs of the service users. Time was spent looking around the home to check the cleanliness, maintenance and decoration. Service users shared their views about the home. Time was also spent observing the contact between service users and staff. Three Care Plans for service users care were examined. The home’s Fire Log, maintenance and nutritional arrangements were checked. An audit of the medication was completed. What the service does well: What has improved since the last inspection? What they could do better: The Statement of Purpose and Service User Guide which provides information to new service users or their families must be updated due to the change in Provider. Some areas of medication must improve. Fire safety instruction records must improve. Two policy and procedures should be provided and records in relation to service users bedroom furnishing should also be in place. Avala Park B53-B03 S553 Avala Park V239267 170505 Stage 4.doc Version 1.40 Page 6 Care plans need to provide more detail and reflect service users ability and preference. 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. Avala Park B53-B03 S553 Avala Park V239267 170505 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Avala Park B53-B03 S553 Avala Park V239267 170505 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 & 3 The Statement of Purpose and Service User Guide are adequate but do not provide all the required information. Service users have their needs assessed prior to admission to the home. EVIDENCE: The Statement of Purpose and Service User Guide must be updated due to the change in Provider. Service users views should also be included in the Service User Guide as recommended at the last two inspections. The care plans inspected showed that service users have a full assessment prior to being admitted to the home. Avala Park B53-B03 S553 Avala Park V239267 170505 Stage 4.doc Version 1.40 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8 & 9 Care plans are in place but more information must be recorded to demonstrate actual care being provided. The health needs of service users are met and multi disciplinary working is taking place but accountability records must be in place for some service users. The systems for the administration of medication are appropriate but some areas require improvement. EVIDENCE: Three service user care plans were examined and found to be positive and look at a range of needs. Improvements in health are evident such as increased weight, better mobility and skin care. This is a credit to the homes approach to personal care. Although activities are provided in the home by the activities co-ordinator, care plans do not identify individual social care needs. Some people are unable to join in ordinary activities and alternative occupation should be explored. The inspector provided further information after the inspection. Avala Park B53-B03 S553 Avala Park V239267 170505 Stage 4.doc Version 1.40 Page 10 Accountability charts must be in place for those service users requiring continued care in their rooms due to frailty ie turning and daily nutritional intake. Staff demonstrated their knowledge of service users preferences but this is not recorded such as bathing, dressing and communication. An audit of the medication arrangements was undertaken and some areas require addressing. (See Requirements) Avala Park B53-B03 S553 Avala Park V239267 170505 Stage 4.doc Version 1.40 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13 & 15 Service users have the opportunity to join in a variety of activities. Service users are able to maintain their contacts with relatives and friends. Dietary needs of residents are well catered for with a balanced and varied selection of food available that meets resident’s tastes and choices as well as special dietary needs. EVIDENCE: The activities co-ordinator provides a range of activities for service users which include sing-a-longs, board games, entertainers, arts and crafts and outings. These are enjoyed by the service users. However some service users are unable to join in these activities and other ones should be developed. Individualised care plans should be provided which reflect ability and preference. Relatives and friends are welcome to visit anytime and service users have the opportunity to go out when they want if able. Service users spoke positively about the food. Lunch was unhurried and service users are able to have alternatives to the menu at anytime. The lunch choice was mince and suet crust, carrots, turnip and cabbage with creamed Avala Park B53-B03 S553 Avala Park V239267 170505 Stage 4.doc Version 1.40 Page 12 potato or soap and a stottie. Orange sponge and custard and fresh fruit or icecream were for dessert. The cook spoke in detail about home cooking, baking and fortifying meals with butter and cream for those service users vulnerable to malnutrition. There is evidence of service users improving. Information is available in the kitchen. Pureed/soft food is served separately which is good nutritional practice. The cook was in the process of updating the menus based on service users preferences. Avala Park B53-B03 S553 Avala Park V239267 170505 Stage 4.doc Version 1.40 Page 13 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 & 17 The home has a satisfactory complaints system in place. Service users have their rights as citizens protected. EVIDENCE: No complaints have been made since the last inspection in October 2004. Service users spoke of their good relationships with staff and the manager. Service users are registered to vote and deal with their own mail unless they are unable which is based on legal assessments of competence. Avala Park B53-B03 S553 Avala Park V239267 170505 Stage 4.doc Version 1.40 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 24 & 26 The standard of the environment within this home is good providing service users with a safe, clean and homely place to live. EVIDENCE: A tour of the home was completed and the home was clean, well maintained and decorated. Service users said that they like their home and feel comfortable in their bedrooms. The location and layout of the home is suitable for the service users living at the home. Adequate numbers of bathrooms and toilets are provided for the current number of service users living in the home. Bedrooms are homely and personalised by the service users, relatives or staff. Some bedrooms contained less provision than that stated to meet this standard e.g. number of comfortable chairs. The manager has previously stated that each resident has been asked regarding their preference but this is still not formally recorded in the individual residents records. Avala Park B53-B03 S553 Avala Park V239267 170505 Stage 4.doc Version 1.40 Page 15 Advice was provided regarding improving infection and odour controls. The kitchen was clean and a recent Environmental Health visit 10/8/05 was satisfactory. Food hygiene, stock rotation and use by dates are in place. Avala Park B53-B03 S553 Avala Park V239267 170505 Stage 4.doc Version 1.40 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 Staffing numbers are appropriate to the assessed needs of the residents, size and layout and purpose of the home at all times. EVIDENCE: The home maintains the level of staffing in accordance with previous agreements with the local authority and this reflects the size and layout of the building and the needs of the residents currently living in the home. The current levels of staffing are a minimum of 4 care staff on duty during the day and 2 waking night staff. Avala Park B53-B03 S553 Avala Park V239267 170505 Stage 4.doc Version 1.40 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 37 & 38 The Manager is suitably qualified and experienced and provides clear leadership. Policies and procedures are in place to guide the practice of staff but two are not. The health and safety checks are good and the safety of service users and staff are protected however one area requires addressing. EVIDENCE: The Registered Manager has just completed the Registered Managers Qualification Procedures relating to emergency admissions into the home and aggression towards staff are not available. Avala Park B53-B03 S553 Avala Park V239267 170505 Stage 4.doc Version 1.40 Page 18 The Manager stated that staff receive fire instruction but records were not in place. Staff records must be maintained regarding fire instruction at the agreed timescales (every 3 months for night and every 6 months for day staff). Maintenance checks are completed on hot water temperatures, staff call systems, window restrictors and wheelchairs. Avala Park B53-B03 S553 Avala Park V239267 170505 Stage 4.doc Version 1.40 Page 19 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x x x 2 x 3 STAFFING Standard No Score 27 3 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 3 x x x x x 2 2 Avala Park B53-B03 S553 Avala Park V239267 170505 Stage 4.doc Version 1.40 Page 20 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 7&8 Regulation 15 Requirement Identify individual social care needs appropriate to their ability and interests. Accountability charts must be in place for those service users requiring continued care in their rooms due to frailty ie turning and daily nutritional intake. Timescale for action 30/9/05 2. 1 4&5 3. 9 13(2) 4. 38 23(4) Service users preferences must be recorded such as bathing, dressing and communication. The Statement of Purpose and 31/10/05 Service User Guide must be updated due to the change in Provider. Handwritten entries and typed 30/9/05 Medication Adminstration Record (MAR) sheets must be signed and countersigned. An up to date BNF must be obtained. Date creams when opened. Records of staff fire instruction 31/8/05 training must be maintained Day staff 6 monthly & Night staff 3 monthly. Avala Park B53-B03 S553 Avala Park V239267 170505 Stage 4.doc Version 1.40 Page 21 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. 4. 5. Refer to Standard 1 24 37 9 26 Good Practice Recommendations Revise the service user guide and include the views of service users. Outstanding Agree with residents the suitability of furnishings where these fall short of the desired standard and record outcomes in the resident’s individual records. Outstanding. Obtain procedures relating to emergency admissions to the home and aggression towards staff.Outstanding. Consider providing a dedicated fridge for medication in the Treatment Room. Consider providing plastic covered pull cords to be used in bathrooms and toilets for ease of cleaning. Consider double bagging clinical waste. Contact Infection Control Nurse Newcastle General Hospital for free training to be the Infection Control link person. (0191 2733584) Avala Park B53-B03 S553 Avala Park V239267 170505 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection Northumbria House Manor Walks, Cramlington Northumberland NE23 6UR National Enquiry Line: 0845 015 0120 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 Avala Park B53-B03 S553 Avala Park V239267 170505 Stage 4.doc Version 1.40 Page 23 - 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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