Inspection on 16/09/05 for Avandale Lodge Nursing Home

This inspection was carried out on 16th September 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 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

Avandale Lodge Nursing Home 01/03/07

Avandale Lodge Nursing Home 14/04/05

Avandale Lodge Nursing Home 07/12/04

Avandale Lodge Nursing Home 15/04/04

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

CARE HOMES FOR OLDER PEOPLE Avandale Lodge Nursing Home Manchester Road Lostock Gralam Northwich Cheshire CW9 7QA Lead Inspector Denis Coffey Announced Inspection 16th September 2005 09:00 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 Avandale Lodge Nursing Home DS0000018754.V249527.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. Avandale Lodge Nursing Home DS0000018754.V249527.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Avandale Lodge Nursing Home Address Manchester Road Lostock Gralam Northwich Cheshire CW9 7QA 01606 48978 01606 48997 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) Southern Cross Healthcare Services Limited Mrs Siobhan Bailey Care Home 48 Category(ies) of Dementia - over 65 years of age (48), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (13) Avandale Lodge Nursing Home DS0000018754.V249527.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The home is registered for a maximum of 48 service users in the category of DE (dementia) The registered provider must at all times employ a suitably qualfiied and experienced manager who is registered with the Commision for Social Care Inspection. Staffing must be provided to meet the dependency needs of the service users at alll times and will comply with any comply with any guidance which may be issued through the Commission for Social Care Inspection. 14/04/05 Date of last inspection Brief Description of the Service: Avandale Lodge is a two-storey, detached purpose built nursing home. It is in its own grounds. Bedroom accommodation is all single with en-suite facilities. There are lounge and dining facilities on both floors, with access to both floors via the staircase or passenger lift. The home is in a residential area close to Northwich and is on a local bus route. Avandale Lodge Nursing Home DS0000018754.V249527.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over 6 hours; during which time a tour of the premises took place, and staff records and care records were inspected. During the course of the inspection, five residents and five members of staff were spoken with. All of the requirements made at the last inspection had been complied with. What the service does well: What has improved since the last inspection? What they could do better: There are six baths provided at the home, however only two of these have suitable aids to assist residents to get in and out of the bath. A requirement has been made for the owners to provide additional bathing aids so that residents can have baths as needed. The overall standard of records regarding the staff records was good, but these could be improved by ensuring that a record is maintained in them of the number of hours each member of staff is employed for each week. Avandale Lodge Nursing Home DS0000018754.V249527.R01.S.doc Version 5.0 Page 6 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. Avandale Lodge Nursing Home DS0000018754.V249527.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 Avandale Lodge Nursing Home DS0000018754.V249527.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): 1, 2 & 3 Residents are assessed and given information to make sure that they know their needs can be met at the home and what their rights and responsibilities are whilst living there. EVIDENCE: The home has a statement of purpose and service users’ guide that was on display in the foyer. People taking up residence at the home are issued with a written statement of terms and conditions that identifies the services provided within the fee payable, additional services available that are not covered by the fee, and the periods of notice required by both parties for termination of the agreement. Records were also seen of new residents being assessed by a trained nurse prior to them taking up accommodation at the home. The home does not provide intermediate care; therefore, Standard 6 does not apply. Avandale Lodge Nursing Home DS0000018754.V249527.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, 9 & 10 Effective care planning and monitoring means that residents’ social and healthcare needs are met prompty by the staff at the home. Residents are encouraged to make decisions, and lead an independent life as possible. EVIDENCE: The care records of four residents were examined at this inspection. All of these contained plans of care addressing the identified needs/problems of the residents, and evidence was seen of the plans being reviewed on a regular basis. The records also contained risk assessments, e.g. falls and nutrition, and assessments with regard to safe moving and handling and continence. A daily record was made of the residents’ health and welfare that was informative. Medicines were stored securely, and a random selection of medicines chosen for stock reconciliation was found to be correct. The Medicine Administration Record sheets of the residents were filled in correctly. Staff were observed to assist the residents in a friendly and supportive manner, ensuring that their dignity and privacy was maintained when providing personal care. Residents and visitors spoken with said that they were happy with the standard of care provided. Avandale Lodge Nursing Home DS0000018754.V249527.R01.S.doc Version 5.0 Page 10 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 Social activities are well managed, providing variety and interest for people living at the home and the residents were happy with the standard of food provided. EVIDENCE: The home employs an activities organiser for thirty hours each week who has recently returned to work following long term leave. A weekly programme of activities has been established, and the current weeks planned activities were on display on a notice board that included activities such as; darts, dominoes, nail care and knitting. There have been three trips to a safari park this summer, and the home manager said that plans were underway to organise afternoon tea dances. Four sets of visitors present at the time of inspection were spoken with, all of who said that they were happy with the care provided, adding that they were kept informed of the health and welfare of their relative. Residents were dressed appropriately in their own clothes, and are able to exercise choice within their ability to do so. Independent advocacy is provided through Age Concern for two residents who do not have a family member/representative to act on their behalf. Lunch on the day of inspection was corned beef hash or soup and sandwiches. Staff were heard asking residents which of these they wanted. Avandale Lodge Nursing Home DS0000018754.V249527.R01.S.doc Version 5.0 Page 11 Mandarin cheesecake was served for dessert. Residents spoken with were positive in their comments about the standard of food provided. Avandale Lodge Nursing Home DS0000018754.V249527.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 There is information available to guide residents and relatives on how to make a complaint and who to make it to. There are procedures and guidance available for staff to ensure that residents are protected from abuse, harm and poor practice. EVIDENCE: There has been one recorded complaint received at the home since the last inspection. A detailed response to the complainant was seen outlining the actions to be taken in response to the issues they raised. Information given by the manager identified that staff have received abuse awareness training and that further training in this was to be provided for staff who as yet had not received it. Avandale Lodge Nursing Home DS0000018754.V249527.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): 20, 21 & 26 The standards of décor, furnishings and hygiene are good, providing residents with safe, comfortable and homely surroundings. EVIDENCE: There are separate lounge and dining rooms on each floor of the home. One of the lounges has been designated as a smoking area for residents. There are two enclosed garden areas at the home for use by the residents. One of these was equipped with garden tables and chairs, whilst the other garden was in the process of having raised flowerbeds installed to enable the residents to participate in gardening. This garden has also had a garden well and water feature supplied. The home has purchased a new carpet shampooer since the last inspection, and has now its own laundering facilities that are equipped with washing machines, tumble driers and ironing equipment. Previous to this facility, the home was having its laundry and the personal clothing of the residents laundered by its sister home situated in the same grounds. Avandale Lodge Nursing Home DS0000018754.V249527.R01.S.doc Version 5.0 Page 14 All of the rooms have the ensuite facilities of a toilet and wash hand basin. There are six baths at the home, three on each floor. Only one bath on each floor is fitted with a rise and fall chair for use with residents who cannot get into and out of a bath unaided because of their mobility problems. The majority of the residents at the home require such assistance. Such equipment should be fitted to other baths at the home, or showers installed in place of the domestic baths. All parts of the home were visited at this inspection and found to be clean, tidy and free from unpleasant smells. See Requirement 1 Avandale Lodge Nursing Home DS0000018754.V249527.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): 27, 28 29 & 30 There are enough staff rostered to be on duty to meet the needs of the residents at all times. Recruitment procedures include thorough checks of all new staff which are needed to ensure that the residents are protected from any possible harm. EVIDENCE: Staff duty rotas showed that the agreed staffing levels were being complied with. 44 of the care staff have attained an NVQ level 2 in care, and other care staff employed at the home are currently undertaking training leading to this award. Three staff files were chosen for examination. All of these contained completed application forms, two satisfactory references. Records were seen of satisfactory enhanced Criminal Record Bureau (CRB) disclosures being obtained for two of these staff. There was a protection of vulnerable adults check carried out on the third staff member, and the manager said that this person would be supervised at all times when providing personal care to the residents until their CRB disclosure had been obtained. Two of these three files did not contain a record of the number of hours the staff were employed for each week. See Requirement 2 Avandale Lodge Nursing Home DS0000018754.V249527.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, 33 & 38 The home is well managed and residents views are taken into account so they have an influence in how the home is run. The practices in the home ensure that that residents are safe and their welfare is promoted. EVIDENCE: The manager at the home has been registered with the Commission as the registered manager since the last inspection. She is a trained nurse with previous experience of working in a care home environment and has achieved the registered manager’s award within the last couple of months. The manager for the home has developed a business plan for the period October 2005 to September 2006. This addresses such areas as staff training and development needs, identified resources for this period, and a redecoration programme. Avandale Lodge Nursing Home DS0000018754.V249527.R01.S.doc Version 5.0 Page 17 There has been a small fire at the home recently that was attributed to a faulty light fitting in a linen room. The fire was contained, and residents evacuated until the fire service decided that it was safe for them to go back into the home. As a result of this, the company owning the home have decided to bring forward by eighteen months the servicing and testing of the home’s electrical wiring. Records were seen of the fire alarm and emergency lighting systems being tested on a weekly basis, and of a visual inspection of the fire extinguishers, weekly. The majority of the staff have undertaken fire safety training this year, and the manager said the remaining staff will have received this by the end of the year. The home was in receipt of a gas safety certificate issued in April this year. Thermostatic valves are fitted to the baths to control the temperature of the hot water supplied to them, and when tested, the temperature of the water was within acceptable limits. Avandale Lodge Nursing Home DS0000018754.V249527.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 3 3 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 x 3 x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x x x x 3 Avandale Lodge Nursing Home DS0000018754.V249527.R01.S.doc Version 5.0 Page 19 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. 1 Standard 21 Regulation OP23 Timescale for action Sufficient numbers of baths or 05/12/05 showers to meet the needs of residents who are old and infirm or physically disabled must be provided. The records of all persons 05/11/05 employed at the home must include the number of hours for which they are employed each week. Requirement 2 29 OP17 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 Avandale Lodge Nursing Home DS0000018754.V249527.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Northwich Local Office Unit D Off Rudheath Way Gadbrook Park Northwich CW9 7LT 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 Avandale Lodge Nursing Home DS0000018754.V249527.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. 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