Inspection on 18/12/06 for Aveley Lodge

This inspection was carried out on 18th December 2006.

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

Other inspections for this house

Aveley Lodge 02/09/08

Aveley Lodge 03/03/08

Aveley Lodge 03/09/07

Aveley Lodge 23/04/07

Aveley Lodge 19/05/06

Aveley Lodge 13/01/06

Aveley Lodge 18/03/05

Aveley Lodge 28/07/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Aveley Lodge Abberton Road Fingringhoe Colchester Essex CO5 7AF Lead Inspector Neal Cranmer Key Unannounced Inspection 09:30 12 and 18th December 2006 th 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 Aveley Lodge DS0000017757.V302294.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. Aveley Lodge DS0000017757.V302294.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Aveley Lodge Address Abberton Road Fingringhoe Colchester Essex CO5 7AF 01206 729304 01206 729304 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) Mr Robin Parmenter Dr Anthony Snell, Mrs Jenny Snell Manager post vacant Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21) of places Aveley Lodge DS0000017757.V302294.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may accommodate 21 persons of either sex who only fall within the category of Old Age 19th May 2006 Date of last inspection Brief Description of the Service: The home is owned by Dr and Mrs Snell and Mr Parmenter. Mr Parmenter is currently acting as the manager of Aveley Lodge. The home is situated in the village of Fingringhoe, Essex, and benefits from being within reasonable bus/car ride of a range of local amenities provided by the historical town of Colchester. Aveley Lodge offers a number of single rooms, some of which have en-suite facilities. The home has two lounges and a conservatory area. Extensive grounds can be found to the rear of the property. The range of monthly fees supplied to the Commission for Social Care Inspection (CSCI) on the 19th May 2006 is between £1,400 and £1,560 per month with an additional charge being made for hairdressing. This information was provided verbally to the inspector at the time of the inspection. Aveley Lodge DS0000017757.V302294.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second unannounced key inspection of the home for this inspection year, which took place over two days in December 2006. During the inspection discussion took place with a number of service users, one relative, the proprietor, acting manager and staff. Service users spoken with during the inspection spoke positively about the environment and cleanliness of the home. A tour of the premises was undertaken, which found the home to be decorated and maintained to a very good standard. During the course of the inspection a range of documentary evidence was sampled. Twenty-three of the thirty-eight standards were inspected, of these nine were met, nine were partially met, with the remainder constituting major shortfalls. What the service does well: What has improved since the last inspection? What they could do better: The home’s medication administration practice needs to be improved upon. The home needs to give consideration as to how it may provide service users with daytime stimulation. The home needs to consider ways in which service users can be supported to make choices about meals provided. The responsible person must ensure that at all times there are sufficient staff on duty to meet the needs of service users. The home’s recruitment practice needs further development to ensure that it adequately protects service users. Aveley Lodge DS0000017757.V302294.R01.S.doc Version 5.2 Page 6 • • • • The responsible person must ensure that staff is provided with the training necessary to enable them to carry out their roles safely and effectively. The responsible person must make provision for a registered manager to be appointed who will have responsibility for the day-to-day running and management of the home. The responsible person needs to give consideration as to how to develop mechanisms for ensuring that the home is run in an open and transparent way. The home’s quality assurance process continues to require further development to ensure that it is based upon the views of service users and other interested stakeholders. 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. Aveley Lodge DS0000017757.V302294.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Aveley Lodge DS0000017757.V302294.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Service users can expect that their needs will be assessed prior to a service being offered. Service users referred solely for intermediate care can expect to be supported to maximise their independence, to enable them to return home. EVIDENCE: The home has in place a pre-admission assessment process for assessing referrals made, which covered, date of admission, details of the person’s next of kin, emergency contact details, general practitioners’ details, general and physical health needs, mental health status, mobility, dietary needs, pastimes and hobbies and social history. Aveley Lodge DS0000017757.V302294.R01.S.doc Version 5.2 Page 9 The home continues to provide intermediate care, although at the time of the inspection there were no service users in residence who had been admitted for intermediate care. Aveley Lodge DS0000017757.V302294.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is Poor. This judgement has been made using available evidence including a visit to this service. Service users cannot be assured that their personal and social care needs will be reflected in their plans of care. Service users can expect that their healthcare needs will be well met. Service users cannot be assured that the home’s practice in relation to the administration of medicines is sufficiently safe and robust. Service users can be assured that they will be treated in a dignified way, and that their right to privacy will be respected. EVIDENCE: Care plans (as identified during the previous inspection) continue to require further development to ensure that the guidance provided to staff on how to support service users towards meeting the identified need is sufficiently specific enough to enable carers to understand the needs of service users. Aveley Lodge DS0000017757.V302294.R01.S.doc Version 5.2 Page 11 All service users are registered with a general practitioner, and records relating to service users healthcare needs were well maintained. Discussion with a visiting district nurse indicated that the home manages service users healthcare needs well, referring service users quickly whenever necessary. Medication is dispensed directly from a medi-dose box or named containers, supplied directly from the local pharmacy. The home does not maintain any controlled medicines. Discussion with the acting manager indicated that all staff had received training in the administration of medicines. However during observation of practice it came to light that this was not the case, sampling of records at this time evidenced that medication was being administered, but not signed for at the time of the administration. Observation of interactions between staff and service users gave no rise for any concerns about the way in which service users privacy and dignity was maintained, staff were heard to speak to and with service users in an appropriate manner, and by their preferred terms of address. Discussion with the visiting district nurse indicated that all medical interventions take place in the privacy of service users rooms. Aveley Lodge DS0000017757.V302294.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is Poor. This judgement has been made using available evidence including a visit to this service. Service users cannot be assured that the home will provide activities that suit their recreational interests and needs. Service users can expect to be supported to maintain links with their families and friends. Service users can expect to be supported to exercise choice and control over their lives. Service users can expect to receive a diet that is wholesome and nutritious. EVIDENCE: There was little evidence seen of there being any stimulating activities going on within the home, this was mentioned by a number of service users as well as a relative, one service user spoke of sitting in the same chair all day watching T.V and snoozing. Aveley Lodge DS0000017757.V302294.R01.S.doc Version 5.2 Page 13 Discussion with service users and a relative of a service user indicated that there are no restrictions on visiting the home, and that they were free to receive their visitors in private. Service users are supported to handle their own financial affairs for as long as they are able, and are free to bring personal possessions with them when they move into the home. The home has recently appointed a cook to the home, with additional weekend cover, so that a cook is available throughout the week, meals are provided three times daily, at least one of which is cooked. There is currently no mechanism in place to enable service users to make any choice, service users who require their meals provided in a purified way receive their meal individually presented, meals were witnessed to take place in a relaxed and homely atmosphere. Meal stocks sampled on the day of the inspection were found to be adequate. Service users spoken with spoke of meals provided being nice. Aveley Lodge DS0000017757.V302294.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. Relatives did not feel assured that concerns raised would necessarily be listened to, taken seriously and acted upon. The home’s adult protection procedures need to be more robust to ensure they adequately protect service users. EVIDENCE: There have been no complaints made in respect of the home since the previous inspection, to either the home or the Commission for Social Care Inspection. Discussion with the acting manager indicated that the home does not maintain a complaints log, and the home’s complaints policy had not been reviewed since 2003, any reference within the policy of CSCI acting as a complaints investigation agency needs to be removed. Discussion with one relative indicated some concern about how concerns expressed are handled by the management team. The home’s Adult Protection policy/procedure continues to provide basic information, although information requires further development to ensure that guidance to staff on what action to be taken in the event of an allegation of abuse being brought to their attention requires improvement. Evidence was provided that all staff have received training in adult protection. Aveley Lodge DS0000017757.V302294.R01.S.doc Version 5.2 Page 15 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. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Service users can be assured that they will be supported in a home that is safe and well maintained to a high standard. Service users can be assured that the home will be kept clean and pleasant. EVIDENCE: The layout of the home is suitable for its stated purpose, being accessible, safe and very well maintained. The environment is comfortable and homely, having a number of lounge areas in which to relax. The grounds of the home are kept tidy and appeared to be safe and accessible to service users via patio doors which lead onto ramped egress who are wheelchair bound. Aveley Lodge DS0000017757.V302294.R01.S.doc Version 5.2 Page 16 The home’s laundry facility is situated well away from food preparation areas, and in no way intrudes upon service users. The floor was semi permeable, and the wall covering was easily cleanable. On the day of the inspection the home was very clean and tidy and was free of any unpleasant odours. Aveley Lodge DS0000017757.V302294.R01.S.doc Version 5.2 Page 17 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. Quality in this outcome area is Poor. This judgement has been made using available evidence including a visit to this service. Service users cannot be assured that their needs will be met by the appropriate number of staff, or that they will always be in safe hands. Service users cannot be assured of being protected by the home’s recruitment practice. Service users cannot be assured that all staff are appropriately trained and therefore competent to carry out their roles. EVIDENCE: Staff providing personal care at the home are all aged over eighteen and those being left in a position of being in charge of the home are all aged over twentyone. A record of the home’s duty rota was maintained, which showed that the home now employed two cooks, who between them cover seven days a week, domestic cover was also seen to be provided. A number of the care team employed by the home have limited use of the English language, and there was concern that the skill mix of the staff is inadequate to meet the needs of the service users. Aveley Lodge DS0000017757.V302294.R01.S.doc Version 5.2 Page 18 This predominantly appears to be due to inflexible work patterns, this matter was recognised by the management team who were trying everything they could to resolve this matter. Very few of the staff team currently hold any N.V.Q qualifications, and there were some serious gaps in terms of staff training, in particular medication training. Three of the home’s staff files were sampled to assess the home’s recruitment practice, a number of gaps were noted in relation to the documentary evidence held, these were as follows: • • • • • • On one file there were no written references Only one of the three files had an employment commencement date. One file did not have a Criminal Records Check. None of the files sampled had any evidence of any induction having been provided. None of the files had any evidence of formal supervision being provided. One file did not contain any evidence of any training being provided. In the view of the inspector the above gaps indicate that the home’s recruitment practice is not sufficiently robust to ensure that service users are protected. Aveley Lodge DS0000017757.V302294.R01.S.doc Version 5.2 Page 19 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, 32, 33 and 38. Quality in this outcome area is Poor. This judgement has been made using available evidence including a visit to this service. The home is currently not be managed by anyone who has been assessed as being competent to do so. There are issues about the ethos and management style within the home. Appearance would suggest that the home is run in the interest of service users, however written evidence to support this view is limited. The home’s practice around health and safety matters is generally good, and protects and promotes service users welfare. Aveley Lodge DS0000017757.V302294.R01.S.doc Version 5.2 Page 20 EVIDENCE: The home continues not to have a registered manager in post, although the acting manager spoke of their intention to put forward an application to become the home’s registered manager. Written evidence was provided of the acting manager having applied for the Registered Managers Award. Discussion with members of the staff team indicated that the process for managing the home in an open and transparent manner could be better, although all of those spoken with indicated that they felt the acting manager provided them with a sense of leadership and direction. The home’s quality assurance process continues to require further development to ensure that it reflects the views of service users and other interested stakeholders. The home’s safe working practices were sampled through the viewing of the following safety certificates: • • • • • Environmental Health Officers report Electrical installation certificate Record of emergency lighting tests Record of hot water checks Gas installation certificate. Written evidence was provided of staff having received foundation training in safe working practices. Aveley Lodge DS0000017757.V302294.R01.S.doc Version 5.2 Page 21 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 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 2 3 x X X X X X 3 STAFFING Standard No Score 27 2 28 1 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 2 2 X X 2 X 3 Aveley Lodge DS0000017757.V302294.R01.S.doc Version 5.2 Page 22 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 OP9 Regulation 18 (ci) Requirement Timescale for action 28/02/07 2. OP12 16 (n) 5. 6. OP27 OP29 18 (a) 18 The responsible person must ensure that all staff receive training appropriate to the work that they are to perform The responsible person must 31/03/07 make provision for providing recreational activities that are suitable to the needs of the service users. The responsible person must 28/02/07 ensure that the home is appropriately staffed at all times. The responsible person must 31/03/07 ensure that all the documentary evidence pertaining to staff recruitment is held on file as per the requirements of Schedule 2 of the Care Homes Regulations. The previous timescales of June 2005, 31st October 2005 and 28th February 2006 and 28/08/06 were not met. The responsible person must make provision for the appointment of an individual to manage the care home. The previous timescale of 31st March and 31/08/06 2006 were not met. DS0000017757.V302294.R01.S.doc 7. OP31 8 31/03/07 Aveley Lodge Version 5.2 Page 23 8. OP36 18 (2) The responsible person must ensure that all staff working at the home receive appropriate supervision. The previous timescales of June 2005, 31st October 2005 and 31st March 2006 were not met. The responsible person must ensure that all staff receive necessary training in safe working practices to ensure that service users and their health and safety are protected and promoted. The responsible person must develop a process for reviewing and keeping under review the quality of the home’s service provision. 28/02/07 9. OP30 18 (i) 28/02/07 10. OP33 24 31/03/07 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 OP15 Good Practice Recommendations It is recommended that the responsible person give consideration as to ways in which to consult with service users on the provision of meals. It is recommended that the responsible person make provision for staff to acquire N.V.Q level 2 qualifications. 2. OP28 Aveley Lodge DS0000017757.V302294.R01.S.doc Version 5.2 Page 24 3. OP32 It is recommended that the responsible person look at ways in which the home maybe managed in an open and transparent way. It is recommended that the service users’ care plans be further developed by expanding on the level of guidance provided to staff on how the identified need objective should be met. 4. OP7 Aveley Lodge DS0000017757.V302294.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Aveley Lodge DS0000017757.V302294.R01.S.doc Version 5.2 Page 26 - 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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