Inspection on 14/03/06 for Avery Lodge

This inspection was carried out on 14th March 2006.

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

Avery Lodge 20/08/09

Avery Lodge 05/05/09

Avery Lodge 08/05/08

Avery Lodge 24/05/07

Avery Lodge 15/06/06

Avery Lodge 09/05/05

Avery Lodge 13/12/04

Avery Lodge 17/05/04

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 Avery Lodge 93 Southtown Road Great Yarmouth Norfolk NR31 0JX Lead Inspector Mr Christopher Handley Unannounced Inspection 14th March 2006 09:45 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 Avery Lodge DS0000028591.V286092.R01.S.doc Version 5.1 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. Avery Lodge DS0000028591.V286092.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Avery Lodge Address 93 Southtown Road Great Yarmouth Norfolk NR31 0JX 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) 01493 652566 01493 603627 Mr Karl Michael Hodgins Mrs Sheryl Anne Hodgins Care Home 13 Category(ies) of Old age, not falling within any other category registration, with number (13) of places Avery Lodge DS0000028591.V286092.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Thirteen (13) Older People of either sex may be accommodated One (1) Service User who is under the age of 65 years and is named in the Commission’s records may be accommodated. Total number not to exceed 13. Date of last inspection 9th May 2005 Brief Description of the Service: Avery Lodge is a detached property situated in a central location between Great Yarmouth and Gorleston. It is owned and managed by Mr & Mrs Hodgins. It is registered as a care home to accommodate 13 older people. The home is a three storey building with bedrooms situated on the ground and first floors. The accommodation is spacious and has 11 single and 1-shared bedrooms; nine of the bedrooms have en-suite facilities. The communal areas consist of three lounges and one dining room, all on the ground floor. Access to the first floor can be via a chair or shaft lift. The front garden has been landscaped and has a seating area overlooking the pond and flowerbeds and the rear has a small car parking area, both enable wheelchair access. Avery Lodge DS0000028591.V286092.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection commenced at 9.45am and finished at 3.30pm. The Inspector spoke to 4 members of staff and 4 residents. A wide range of documentation was seen and read, and a tour of the home was undertaken by the Inspector accompanied by the Proprietor. The home was neat, clean and warm at the time of the inspection. The Inspector has not inspected this home previously. What the service does well: What has improved since the last inspection? What they could do better: The home is in the process of applying for a variation in registration so that it will more accurately reflect the present state of residents, which over the years has changed. Avery Lodge DS0000028591.V286092.R01.S.doc Version 5.1 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. Avery Lodge DS0000028591.V286092.R01.S.doc Version 5.1 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 Avery Lodge DS0000028591.V286092.R01.S.doc Version 5.1 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 The home obtains comprehensive information prior to a resident being admitted to the home. EVIDENCE: The Proprietor obtains a wide range of information about residents prior to them being admitted to the home, and the Inspector was shown this information which had been supplied by the Social Worker. The document is clearly marked Confidential Information. The information provides a very clear picture of the residents’ needs and abilities. Avery Lodge DS0000028591.V286092.R01.S.doc Version 5.1 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 & 11 All residents have an individual care plan. The medicine system in the home is safe and effective. Death is dealt with in a very sensitive manner, with the rights of the residents being respected. EVIDENCE: All residents have an individual care plan, which is kept in a locked container. The care plan contains an assessment, plan implementation and review. The Inspector read three sets of care plans. Residents are involved in the care planning process, or if they are too frail, then a relative is invited to assist with the resident’s wishes. The writing in these records is neat and tidy. Risk assessment documentation was also read. Avery Lodge DS0000028591.V286092.R01.S.doc Version 5.1 Page 10 The Proprietor explained the home’s medicines system. When medicines are delivered to the home they are locked away until there is time to store them properly. The home uses a Monitored Dosage System. All staff who administer medicines have had training for this. The medicines are kept in Doset boxes which were neatly stored in a locked cupboard. There were no loose or unaccounted for medicines. The medication charts are neatly recorded. There are no Controlled Drugs in the home, but there are facilities for them should they be needed. There are no residents who self medicate the Proprietor said. If there are any difficulties with a medicine the prescribing Doctor is contacted. The home enjoys a good working relationship with the supplying pharmacist. The home has clearly written guidelines for the use of staff on reception, storage, administration, recording, and disposal of medicines. The Proprietor said that care and comfort is provided to residents at all times but especially when a resident is dying. Pain relief, if needed, is provided, the wishes of the resident, and where applicable the family, are known and they are carried out. The family and friends of the dying resident are kept informed. Privacy and dignity are provided at all times. Residents are not moved from their room when they are dying, but stay in their rown room surrounded by familiar objects. The representative of the resident’s religion is informed if that is the wish of the resident. Family and close friends of the dying residents may stay overnight if they wish the Proprietor said, with refreshments being provided. The body of the resident who has died is handled with great care, and the last offices are provided. The home has polices and procedures for care of the dying. Senior staff support junior staff at such times. Avery Lodge DS0000028591.V286092.R01.S.doc Version 5.1 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): 15 The home provides nutritious meals which the residents like. EVIDENCE: The cook told the Inspector that he sees residents on the day they are admitted in order to ascertain their likes and dislikes. He also asks on a daily basis their choice of food for the day. The residents interviewed spoke very well of the meals provided. The menu was seen by the Inspector and it appeared varied, nutritious and interesting. Special diets are provided, but they are not recorded and the Inspector advised the Proprietor that it was required that this should be the case. The cook has developed a good relationship with the residents, and the kitchen though busy was neat and tidy. Because of the potential dangers in the kitchen the Inspector recommends that all kitchen staff undertake training in First Aid so that should an accident occur the staff will have the skills to deal with the event. Avery Lodge DS0000028591.V286092.R01.S.doc Version 5.1 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): 16,17 & 18 The home has a complaints procedure which is publicly displayed. Residents’ legal rights are protected. All staff have undertaken training in Adult Abuse Prevention. EVIDENCE: The home’s complaints procedure is posted up in the front hall. It is clearly set out and it is in large print, which may assist those who may have poor sight to read it. Residents spoken to knew what action they would take most saying that they would speak to the first member of staff. There have been no complaints since the last inspection. Residents’ legal rights are protected and the Proprietor said that if needed she would arrange that advocacy would be arranged and informed the Inspector that Age Concern in the area had sound arrangements in hand for such events to be dealt with. All staff have had training in the Prevention of Adult Abuse, the Proprietor said, and two members of staff spoken to confirmed this. The Proprietor is aware that the clients which the home cares for are very much at risk in this matter, and she is alert to the fact that these matters can go on for some time before people are aware of it. Avery Lodge DS0000028591.V286092.R01.S.doc Version 5.1 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): 21,24. The toilets are tidy and clean and fresh smelling. The bedrooms are neat and tidy, and reflect the individuality of the residents. EVIDENCE: During the tour of the home the Inspector saw the toilet facilities. The toilets are on the ground and first floor. There are four bedrooms on the ground floor, three of which have their own toilets. There are twelve bedrooms on the first floor, six of which are en suite. All the toilets are neat and clean and fresh smelling, there are grab rails in place, and they provide privacy for the users. A wide selection of bedrooms were seen by the Inspector accompanied by the Proprietor. There are bedrooms on the ground and first floor. There is a lift to the first floor. Avery Lodge DS0000028591.V286092.R01.S.doc Version 5.1 Page 14 All the bedrooms seen were neat clean and tidy and some have ornaments and pictures which belong to residents and give the rooms an individual appearance. All the rooms are well decorated, and well furnished. Three of the residents spoken to said that their rooms were very comfortable, and were always “nice and warm”. Medication is not kept in residents’ rooms the Proprietor said. Avery Lodge DS0000028591.V286092.R01.S.doc Version 5.1 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): 28 & 29 Staff are trained to do their jobs. The home has sound recruitment practice. EVIDENCE: The Proprietor described the training which takes place in the home. There 9 staff who have NVQ II out of 14 staff. Of these there are 5 who have completed NVQ level III. The home is commended for this level of training, 64 . All staff have taken the Certificate in Mental Health, which enable them to meet the needs of those residents who have mental health problems. The Proprietors appreciate the importance of training, and both they and the staff are commended for the hard work that they have put into this matter. The Proprietor described the home’s recruitment practice in detail. Avery Lodge DS0000028591.V286092.R01.S.doc Version 5.1 Page 16 All posts are advertised. All staff are interviewed by two staff, there is good interview preparation. CRB and POVA checks are carried out. Two written reference are obtained. All staff are supplied with a Job Description, Contract, Terms and Conditions and a copy of the Code of Practice. All staff undergo an induction programme, a copy of which was seen by the Inspector. All new staff are shadowed by a member of staff when they start. The Proprietor realises the importance of selecting staff and takes all the steps possible to get the right staff for the home. The home has a very low turnover of staff, the Proprietor said. Avery Lodge DS0000028591.V286092.R01.S.doc Version 5.1 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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): 32,33,34,35 & 36 The Proprietor has a clear sense of leadership and direction. The home holds the quality assurance certificate of Investors in People Award. The home holds all the financial documents required. The home does not hold any monies or valuables on behalf of residents. All staff is appropriately supervised. Avery Lodge DS0000028591.V286092.R01.S.doc Version 5.1 Page 18 EVIDENCE: The Proprietor has a very positive approach to providing a high quality of individual care for residents. She has a clear direction and has leadership skills which staff recognise and appreciate. She is a strong believer in training and developing staff and this is shown in the 64 of staff who have NVQ. The management of the home is open and transparent. The Proprietor has undertaken a wide range of training including the City and Guilds Certificate, Care Management, D 32/33. The home holds the quality assurance guarantee of Investors in People, and the insignia for this is displayed in the main hall of the home. The Proprietors believe in providing a quality service. The Proprietor undertook to send the next report to the Norwich office, which is due in April. The home holds the financial documentation required. The certificate of insurance was seen in the main hall, this was for the appropriate amount required. The Proprietor showed the Inspector records of transactions. The Inspector was shown documentation which shows that the home is financially viable. The Proprietor informed the Inspector that the home does not have the practice of holding any monies on behalf of residents. Any personal items e.g. toiletries are purchased by residents’ relatives. The home does not hold valuables on behalf of residents and the both these practices are made clear to relatives when the person is admitted. Supervision of staff is provided and recorded by the Proprietor Mrs Hodgins said. She finds this is a useful development tool for staff. The items discussed cover practice, training and career development. The records for this are kept locked safe in the member of staff file. Staff spoken to by the Inspector confirmed that supervision took place in the home, and that it was a help when it came to training. Avery Lodge DS0000028591.V286092.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME 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 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 3 10 x 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 x x 3 x x 3 x x 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 x 3 3 3 3 3 x x Avery Lodge DS0000028591.V286092.R01.S.doc Version 5.1 Page 20 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 OP15 Regulation Scd 4 13 Requirement Special diets to be recorded. Timescale for action 15/05/06 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 staff who work in the kitchen because of the potential dangers in that environment undertake training in First Aid. Avery Lodge DS0000028591.V286092.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 Avery Lodge DS0000028591.V286092.R01.S.doc Version 5.1 Page 22 - 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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