Inspection on 23/09/05 for Avenswood

This inspection was carried out on 23rd 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

Avenswood 23/02/07

Avenswood 26/01/06

Avenswood 18/01/05

Avenswood 27/09/04

Avenswood 30/03/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Avenswood 20 Abbotsford Road Blundellsands Liverpool Merseyside L23 6UX Lead Inspector Mrs Julie Garrity Unannounced Inspection 23rd September 2005 11.15 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 Avenswood DS0000017223.V254610.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. Avenswood DS0000017223.V254610.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Avenswood Address 20 Abbotsford Road Blundellsands Liverpool Merseyside L23 6UX 0151 924 0484 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) Nursing Home Management Limited Mrs Ann McDonnell Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places Avenswood DS0000017223.V254610.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service Users to Include up to 18 (OP) The service should, at all times, employ a suitably qualified and experienced Manager who is registered with the CSCI. 18/01/05 Date of last inspection Brief Description of the Service: The Home is registered to provide nursing care. In total the Avenswood Care Home provides care for 18 service users over retirement age. The Home is privately owned. The registered manager has worked in the Home for a several of years and is a registered nurse. The Home is a converted building on 3 floors, there is no passenger lift to the 1st and 2nd floors. However the establishment utilises a scalamobile chair that is designed to ascend the stairs. There are 12 single rooms, 5 bedrooms with ensuite facilities and 3 double rooms none of which have ensuite facilities. Bedrooms are situated on all floors with a lounge/dinning area on the ground floor. There are gardens to the rear of the establishment accessible from the ground floor. Avenswood is situated in a residential area in a quite cul-de-sac. The local train station is accessible at the bottom of the street and there are a number of shops within walking distance. Parking is available to the front of the building. Avenswood DS0000017223.V254610.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over three hours. It was a routine unannounced inspection. Then residents and two care staff member were spoken with. Interviews were held with the manager and discussions were also held with four family members. A tour of the premises was undertaken and care plans and staffing records were reviewed. What the service does well: What has improved since the last inspection? What they could do better: The planned stair lift and conservatory will be of great benefit to the residents living in Avenswood. Several of the residents were looking forward to the conservatory with one resident saying it would be “lovely to sit in the winter and see the garden”. The manager has continued to develop the documentation in the Home and has succeed in the majority of areas still to be developed is the recording of staff training and supervision and the same well written actions available in all the residents care plans. The means to make sure that an appropriate means to keep open fire doors should be put into place when the magnetic system currently in place develops a fault. Avenswood DS0000017223.V254610.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. Avenswood DS0000017223.V254610.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 Avenswood DS0000017223.V254610.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): There is no judgments to be made on these standards at this time. EVIDENCE: None of the standards listed above were assessed at this inspection. Avenswood DS0000017223.V254610.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, 10 The manager continues to improve the quality of the care plans available in the Home and makes sure that residents, relatives and staff are aware of the needs of the residents and how to meet those needs. The individual rights of residents are respected and acted on. EVIDENCE: The care plans within the home accurately reflect the needs of the residents. Residents or their relatives have been included in reviews of the care. One resident explained, Its nice to know how they are going to look after my mum. In general the actions the staff need to take in order to care for the residents are clear and well written. This good standard was not maintained in all of the actions to be taken by staff, however the quality of care planning was an improvement from previous records viewed. The health care needs of the residence were clearly documented and when external services were used the reasons for this and what treatment had been put into place was clearly documented and explained to the residents. One resident said, If Im ill, the staff look after me well and make sure that the doctor comes to see me. The manager makes sure the residents are supported to be seen by opticians and dentists as appropriate. Avenswood DS0000017223.V254610.R01.S.doc Version 5.0 Page 10 Records regarding monitoring and treatment of pressure ulcers were not detailed enough to make sure that staff can be confident that the treatment they provide is in line with best practice. Residents spoken with were happy that staff respected their right to privacy at all times. One resident said, “ The staff are always polite, speak to me nicely and treat me very well. Avenswood DS0000017223.V254610.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, Resident’s personal preferences are determined and acted on in an appropriate manner. Staff are aware of the different choices of the residents and make sure that they provide the residents with their choices. EVIDENCE: The manager makes sure that the different social needs of the residents are written down to make sure that staff are aware of what the residents wishes are. One resident said, “I came here for 2 weeks, but knew within days I was never going to move out. I have my own room, with my own things and I do what I want when I want. I couldn’t ask for anything more”. Staff have a great deal of knowledge about the individuals that they care for and are aware of their personal preferences. This understanding is supported by good documentation. Families are encouraged to visit the Home, as they and the residents would like them too. All of the relatives spoken with were confident that “the staff really care for” their relatives and that they are always “welcomed” into the Home. Avenswood DS0000017223.V254610.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): 18 The Home makes sure that staff are aware of the need to protect residents there are systems in place that make sure that the residents are protected from potential abuse. EVIDENCE: The home has a training programme for all staff to receive training in the Protection of Vulnerable Adults. There are policies and procedures in the Home that staff are aware of. Discussion with management detailed a clear understanding of the process of Protection of Vulnerable Adults. Staff were clear as to how they would report and concerns that they may have and felt that “it would be addressed very quickly”. Relatives spoken with were aware that the home takes all complaints of any nature seriously. One relative said “I’ve never has any cause to make a compliant. If I did I am sure that matron would but it right very quickly”. Staff records detailed training in Protection of Vulnerable Adults. The manager reported that a number of staff had received training in Protection of Vulnerable Adults, however the written records did not reflect this and are in need of updating. Avenswood DS0000017223.V254610.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, 26 Avenswood is Homely, well presented and clean. EVIDENCE: The home is decorated in a homely manner. Residents are supported to say how they would like the home decorated including their bedrooms. The owner has been negotiating with the Fire authority to install a chair lift to the upper floors of the Home and is planned that this will commence shortly. This will be of great value to the residents in the Home. There are also plans to have a further day room/lounge and build a conservatory. One of the residents said of the plans to build a conservatory “wouldn’t it be lovely”. In general the Home is well maintained and decorated regularly. The residents and relatives were particularly complimentary about the cleaning of the home. One resident said, “It’s always lovely and clean and smells beautiful”. Avenswood DS0000017223.V254610.R01.S.doc Version 5.0 Page 14 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 The Home protect the residents by making sure that the staff recruited are suitable to work in Avenswood and that they 3receive the training necessary in order to do their jobs well. EVIDENCE: The manager detailed that the staff have received a variety of different training and that they support the nursing staff to further expand their nursing skills. Training has included medication training, Protection of Vulnerable Adults, health and safety, moving and handling and first aid. Staff detailed that they had been involved in a lot of training and enjoyed the opportunity. The training that the staff had undertaken was not always recorded and this is because the manager is up dating all staffing files to reflect their training but has not yet completed the task. Residents spoken with were confident that staff “really know their jobs and how to care for me”. A review of staffing files showed that staff were recruited using equality of opportunity and all the relevant checks were undertaken before the staff commenced working in the Home. Avenswood DS0000017223.V254610.R01.S.doc Version 5.0 Page 15 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, 32, 36 The manager supports the residents, relatives and staff in an appropriate manner. A good an approachable ethos is in place that supports the residents and relatives to feel happy and welcome in the Home and create a happy and organised staff team. Staff are given appropriate support through training and supervision. EVIDENCE: The manager is registered with CSCI, she has maintained her nursing skills and has updated her training in management. All of the staff and the residents said that the Home was “well-run” and that the manager was” approachable”, “always available” and “happy to talk at any time”. The manager has worked very hard to update the written records in the Home and has succeeded in the majority of areas. She continues to work on updating the records in the Home and care appropriately for the residents. The manager and the staff say that they receive regularly supervision that is in place to support them to do their jobs fully. The majority of the supervision is recorded, however some of the supervision records were not available. Avenswood DS0000017223.V254610.R01.S.doc Version 5.0 Page 16 The Home has a good fire door system, however one of the door systems had failed and the door was wedged as a temporary measure. This is not appropriate and a temporary measure that responds to the fire alarm will need to be identified. Avenswood DS0000017223.V254610.R01.S.doc Version 5.0 Page 17 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 x x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 3 3 x x x x x x 3 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 3 x x x 3 x x Avenswood DS0000017223.V254610.R01.S.doc Version 5.0 Page 18 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard OP7 OP8 OP36 OP38 Good Practice Recommendations The manager should make sure that all care plans are written to the same good standard viewed. Wound care records should include, photographs and wound mapping. The manager should expand the good practice of recording supervision and training and make sure that a record of both is maintained Arrangements should be put in place for back up fire systems in the event of failure of one of the door systems. Avenswood DS0000017223.V254610.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG 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 Avenswood DS0000017223.V254610.R01.S.doc Version 5.0 Page 20 - 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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