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Inspection on 16/12/05 for Avalon Care Home

Also see our care home review for Avalon Care Home for more information

This inspection was carried out on 16th December 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home provides a domestic and comfortable environment, which is well maintained, in most parts. The manager and staff are very committed to providing good standards of care for the residents. The food is well thought of and residents feel respected and enabled to socialise in a manner that is comfortable for them. The home`s care planning process and a majority of other documentation required meets the National Minimum Standards.

What has improved since the last inspection?

Not all of the National Minimum Standards were assessed on this occasion. According to residents and relatives the home continues to provide a good standard of care in a comfortable and pleasant environment. Nearly all of the requirements set at the previous inspection have been addressed. The manager discussed plans for improving staff support and supervision, which are being introduced very shortly.

What the care home could do better:

The home is required to fit adequate ventilation to the smoking room, which was first required by the 31 January 2005. Records maintained in relation to activities and appliances in the kitchen must be maintained and up to date.

CARE HOMES FOR OLDER PEOPLE Avalon Care Home 116 Clipstone Road West Forest Town Nottinghamshire NG21 9JH Lead Inspector Andrew Sales Unannounced Inspection 16th December 2005 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Avalon Care Home DS0000024627.V270806.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Avalon Care Home DS0000024627.V270806.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Avalon Care Home Address 116 Clipstone Road West Forest Town Nottinghamshire NG21 9JH 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) 01623 644195 01623 429977 Southern Cross Care Homes No 2 Limited Teresa McArdle Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Avalon Care Home DS0000024627.V270806.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The manager must undertake training in the area of adult protection as soon as a course becomes available Service users shall be within category OP Date of last inspection Brief Description of the Service: Avalon Care Centre is a purpose built two-storey, forty bedded care home for older people situated on the outskirts of Mansfield, close to the former mining village of Clipstone. It is situated on a main road, which has a public bus service, and is approximately two miles from Mansfield town centre to the North East. All bedrooms are single occupancy, with half having en-suite facilities. Avalon is close to local shops, and a pub. Avalon Care Home DS0000024627.V270806.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was conducted by A.J.Sales on 16 December 2005. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for residents and their views of the service provided. This process considers the home’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provisions that need further development. The primary method of inspection used was ‘case tracking’ which involved selecting two residents and tracking the care they receive through review of their records, discussion with them, the care staff and observation of care practices. The inspector also spent time talking to other resident’s in the home and two members of staff. Overall the feedback was very good. Residents were happy to express their views about the home, they were positive in terms of the skills and attitude of the staff and of the overall standards of care, food, social recreation and the environment. What the service does well: What has improved since the last inspection? Not all of the National Minimum Standards were assessed on this occasion. According to residents and relatives the home continues to provide a good standard of care in a comfortable and pleasant environment. Nearly all of the requirements set at the previous inspection have been addressed. The manager discussed plans for improving staff support and supervision, which are being introduced very shortly. Avalon Care Home DS0000024627.V270806.R01.S.doc Version 5.0 Page 6 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. Avalon Care Home DS0000024627.V270806.R01.S.doc Version 5.0 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 Avalon Care Home DS0000024627.V270806.R01.S.doc Version 5.0 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 the following standard(s): 3,4. Residents are fully assessed before they are admitted and regularly reviewed thereafter. The provider is fully capable of meeting the needs of residents it accepts. EVIDENCE: Two residents were case tracked spoken with. All of the assessments were comprehensive and contained sufficient information to enable staff to ensure that they could meet the residents assessed needs. One resident in particular spoke of her admission to the home, which has greatly improved her quality of life in terms of stimulation, environment and services available. The resident concerned was admitted with nursing needs but now only requires residential personal care and support, she was particularly complimentary about the home, the staff and the way she is able to exercise choice in her every day life. Avalon Care Home DS0000024627.V270806.R01.S.doc Version 5.0 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 the following standard(s): 7,8,9,10. Each resident has an individual plan of care. Resident’s health needs are well met. Residents are protected by Avalon’s medication policies and procedures. Residents feel safe, and are treated with respect, their dignity and privacy is respected. EVIDENCE: Two residents were case tracked. Care plans and risk assessments were inspected. Plans contained all areas of assessment required in this standard. Outcomes for residents were discussed during individual discussions with the inspector and the individual. All stated that they were satisfied with the standards of care they received and the way their support is planned. There is evidence on care plans of cognitive assessments, weight management and monitoring of residents psychological well-being. Residents receive chiropody treatment and other community health services via domiciliary visits. This is documented on care plans. Avalon Care Home DS0000024627.V270806.R01.S.doc Version 5.0 Page 10 Residents also confirmed they are involved in the care planning process. assistant manager and staff state that care plans and risk assessments reviewed. The senior care staff spoken with, confirmed that residents involved in this process. Care plans evidenced reviews that were dated signed. The are are and In a discussion with the member of staff, it was clear they had a thorough understanding of the emotional impact admission to residential care may have on individual residents and were able to describe how they support residents to come to terms with such a transition. Observations were made of professional interaction with residents, which supported resident’s comments that they feel well respected and supported. Staff spoke of a number of training subjects and courses they have attended, which evidence that the staff team is well equipped with a range of skills and experience to meet the needs of residents. Staff training records that were viewed, evidenced that medication training was provided for staff responsible for the administration of medication. The home has a policy and procedure for receipt, recording, storage, handling, administration and disposal of medication. The home’s medication records were not observed as part of this inspection . Avalon Care Home DS0000024627.V270806.R01.S.doc Version 5.0 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 the following standard(s): 12,13,14,15. Residents are supported to pursue, religious and social interests. Residents are helped to exercise choice and control over their lives. Residents receive good quality food and a balanced diet in a relaxing atmosphere with support from staff where required. EVIDENCE: The manager, residents and staff confirmed that the routines of the home are flexibly implemented to suit the preferences of individuals. Residents feel they are kept well informed about local events and available activities. There were many examples of choice being offered during the visit, from a choice of drinks being offered, to people being asked if they would like to take part in one particular activity or another. Observations were made of professional interaction with residents, which supported resident’s comments that they feel well respected and supported. The resident’s who were case tracked confirmed they were very satisfied with the food provided by the home. Two other residents supported this. Lunch was observed by the inspector, staff support was unhurried. Two resident’s rooms that were observed, were well furnished and personalised and they confirmed they are able to bring in their own possessions. Avalon Care Home DS0000024627.V270806.R01.S.doc Version 5.0 Page 12 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 the following standard(s): 16,18. Residents are confident that their complaints will be listened to and acted upon. Residents are protected from abuse. EVIDENCE: The home has a comprehensive complaints procedure, which is appropriately displayed, throughout the home and also forms part of the Statement of Purpose, and Service User Guide. Those residents who were asked if they were made aware of the complaints procedure, confirmed they were and all said they thought their complaint would be taken seriously. There is a file containing records of complaints made in the office and records were observed. The home has an appropriate Whistle Blowing Policy and a copy of the Adult Protection Procedures. The homes policies and procedures for responding to suspicion or evidence of abuse, or neglect, are all satisfactory. All of the residents spoken with said they felt safe, and staff members were able to confirm their understanding of adult abuse procedures. Staff also confirmed that they had received adult protection training, and this was evidenced in the staff training records. Avalon Care Home DS0000024627.V270806.R01.S.doc Version 5.0 Page 13 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 the following standard(s): 19,20,21,22,26. Avalon is a safe and well maintained environment. There are sufficient and suitable lavatories and bathrooms for the residents. There is a range of specialist equipment available to maximise independence. The home is clean, fresh, and hygienic in all areas. A number of environmental requirements have been addressed. EVIDENCE: The home’s gardens are well-maintained and provided very pleasant outdoors space for service users. All residents spoken with stated how pleased they were with the homes décor and furnishings. The inspector observed a range of bathing options within Avalon, with both baths and showers available, and a range of hoisting options to allow the more physically dependant resident to bathe. There are grab rails situated throughout the building to assist with resident’s mobility, together with a passenger lift. Avalon Care Home DS0000024627.V270806.R01.S.doc Version 5.0 Page 14 In respect of the outstanding requirements from the previous inspection; The inspector observed a ramp recently installed to provide wheelchair access to the main building. The manager showed the inspector new door locks and lockable facilities being installed for residents. A new boiler was being installed on the day of the inspection. The smoking room still requires an extractor fan. This is outstanding from 31 January 2005. Avalon Care Home DS0000024627.V270806.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29,30 Staff are recruited in accordance with the homes recruitment procedure, which meets the National Minimum Standards. Staff are trained in mandatory subjects required by this standard and for care specific support. EVIDENCE: There are suitable recruitment policies and procedures that have been observed at previous inspections. One staff file was sampled at random. This contained evidence of applications, interviews, pre employment checks, criminal declarations and training plans. This file contained a CRB with disclosures. The file also contained evidence of training in a number of health and safety subjects, dementia awareness and NVQ level 3. Staff spoken with, informed the inspector of various training courses they had attended, which included, adult protection and the safe handling of medicines. Avalon Care Home DS0000024627.V270806.R01.S.doc Version 5.0 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,36,38. Avalon Care is run in the best interests of its residents. Formal staff supervision is planned. The resident’s health & safety is promoted and protected by Avalon’s policies, procedures and record keeping. A health and safety requirement is outstanding from the previous two inspections. EVIDENCE: Residents said they felt the home was well run and the manager and staff team were always on hand for support and advise. Staff spoken with confirmed that they felt supported by the manager and that they are approachable to discuss any issues. Staff felt that issues were gradually being addressed since the recent appointment of the new manager and were hoping that the home would benefit from a period of stability, following changes in ownership and management. Avalon Care Home DS0000024627.V270806.R01.S.doc Version 5.0 Page 17 The manager showed the inspector plans to introduce the supervision framework. A range of health & safety records covering such things as: Fire, Legionella, Pest Control, Servicing of the Lift and Clinical waste were seen at the last inspection only three months ago. These were very well documented, and recorded and the inspector did not ask to see them on this occasion. The kitchen refrigerator and freezer temperature and other records were inspected and were not up to date. As these cannot be updated retrospectively, a requirement was issued to address this. Avalon Care Home DS0000024627.V270806.R01.S.doc Version 5.0 Page 18 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 3 X X 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 3 3 3 X X X 2 STAFFING Standard No Score 27 X 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X 3 x 2 Avalon Care Home DS0000024627.V270806.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard 26 Regulation Requirement Timescale for action 16/12/05 Regulation The Registered person must 16 (2) k ensure that the hairdressing room used by residents as a smoking room has an extractor fan fitted to keep the room free from offensive odours. Previous timescale set: 31/01/05 not met. 2 38 Regulation The Registered person must 16 ensure that the records relating to the temperatures of the refrigerator and freezer are maintained and are up to date. 16/12/05 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 Avalon Care Home DS0000024627.V270806.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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 Avalon Care Home DS0000024627.V270806.R01.S.doc Version 5.0 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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