Inspection on 15/06/06 for Avery Lodge

This inspection was carried out on 15th June 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 14/03/06

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 Pearson Clarke Key Unannounced 15th June 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.V301428.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. Avery Lodge DS0000028591.V301428.R01.S.doc Version 5.2 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 avery.lodge@btconnect.com 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.V301428.R01.S.doc Version 5.2 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 14th March 2006 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.V301428.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection of the service was unannounced and took place over part of two days. During his time in the home the inspector talked to service users, visitors to the home, staff on duty and on the second day the provider. A tour of the building was undertaken and records were inspected. All of the above helped inform the judgements made. The fee levels for the home on the day of inspection were £325.00 per week to £338.00 per week. What the service does well: What has improved since the last inspection? What they could do better: Avery Lodge DS0000028591.V301428.R01.S.doc Version 5.2 Page 6 The home is managed by the owner and as in many such homes reflects the owners drive and commitment. Recent events have made it difficult for her to maintain her usual input and as such there were some signs of the home suffering as a result. It is understood that normal input from the provider is now to be resumed and there are some issues to address. There has been some turnover of staff and there is a need to ensure that there is a full staff team again. In recruiting all checks need completing in order to ensure safe staffing. The service must not admit people outside of their conditions of registration and if in doubt should consult with the commission. 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.V301428.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 Avery Lodge DS0000028591.V301428.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,5 The overall quality outcome for this group of standards is adequate. Service users have all necessary information available to make an informed choice of home and a satisfactory assessment process, however the service must take care to ensure that its admissions are consistent with its conditions of registration. EVIDENCE: The inspector spent time with the provider exploring the admission process to the home and as such is satisfied that a satisfactory system is in place. Examples were given as to the process, including a prospective new admission. From these it could be seen that service users and their representatives are encouraged to spend time in the home to allow them to make an informed decision and that the service carries out a written assessment of need as part of the admission. The provider confirmed that all people admitted are given a service user guide and that they have a contract. Copies of the contract were seen on service user files and a service user guide is displayed in the entrance hall of the home. Avery Lodge DS0000028591.V301428.R01.S.doc Version 5.2 Page 9 Some discussion took place as to the need for the provider to remain within the services conditions of registration and the tendency for social workers to refer people who may have dementia , but are not felt to need specialist care. The provider is reminded of the need to take care in such situations and if in doubt seek the views of the registration authority before proceeding. Avery Lodge DS0000028591.V301428.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 The overall quality outcome for this group of standards is adequate. Service users have clear plan of care and the care delivered is based on this. Health care needs are met and medication is generally well managed. EVIDENCE: During the inspection four care plans were looked at. The plans seen contain risk assessment’s and have been subject to review. There is evidence within the plan of the service user or their representatives being involved in the process. The plans allow for the tracking of medical inputs and would indicate that health care needs are being met. Sample medication records were inspected and were found to be in order. Although medication was securely stored it was noted that one person was in receipt of a controlled drug and this was stored with the main medication. Best practice for such medication is for it to be securely stored in a separate cabinet, which fully complies with the relevant legislation and a recommendation is made to this effect. Staff have received medication training. No service users self medicate. The inspector spent time with service users both as a group and individually. They told him that they were well cared for and that the staff treated them Avery Lodge DS0000028591.V301428.R01.S.doc Version 5.2 Page 11 with respect. The inspector observed staff respecting residents privacy in their day to day working regime. Avery Lodge DS0000028591.V301428.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 The overall quality outcome for these standards is satisfactory. Service users enjoy a relaxed regime in which they have opportunities for stimulation, tasty food and are able to exercise choice in their day to day lives. EVIDENCE: Service users spoken to by the inspector felt well cared for and able to exercise choice in their routine. The inspector talked to one family of visitors who come to the home on a regular basis. They stated that they always feel welcome and are free to come and go as they wish. Staff keep them informed about their relatives welfare and they feel that good care is offered. All of those spoken to said that they liked the food, describing it as good home cooking. The inspector saw lunch being served and it looked and smelt appetising. The inspection took place during the world cup and it was noted that the service had made a big effort to celebrate, with the home being decorated and posters inviting service users to watch the match. In the entrance hall were posters advertising other social activities and displays of photographs of service users of events that had taken place. Avery Lodge DS0000028591.V301428.R01.S.doc Version 5.2 Page 13 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 The outcomes for this group of standards are judged to be adequate. Complaints are taken seriously and through training and policies, service users are protected from abuse. EVIDENCE: The provider confirmed that there have been no complaints since the service was last inspected. The services complaints procedure was prominently displayed in the main entrance hall and service users spoken to were confident that if they had any issues these would be taken seriously. The provider confirmed that both she and her staff have attended adult protection training and this supports the services policies in this area. Avery Lodge DS0000028591.V301428.R01.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,24,26 The quality outcomes for this group of standards is judged to be good. With service users benefiting from a safe and comfortable home. EVIDENCE: During the inspection the inspector toured the building and sought the views of service users about their environment. All of those spoken to were happy with the levels of comfort and with their bedrooms. Although the service is on a small plot the provider has worked hard to maximise the usability of the garden. This is particularly the case at the front of the home where extensive decking has been laid, which combined with attractive planting gives people a pleasant and accessible place to walk and sit. The home has two lounge areas and a separate dining room and all of these are pleasantly decorated and furnished. There is a homely feel with pictures, plants and photographs used to good effect. In one of the lounges there is a small library area with a good range of books available. The television in the main lounge is of a good quality and size and easily viewed by all who want to. Avery Lodge DS0000028591.V301428.R01.S.doc Version 5.2 Page 15 Bedrooms seen by the inspector were generally personalised by their occupants and in good decorative order. All of the communal areas seen by the inspector were clean and fresh, however it was noted that there was odour in two of the bedrooms. This was discussed with the provider who confirmed that there were significant problems establishing a satisfactory continence management regime for the service users concerned. As such the inspector would encourage the provider to continue to explore ways in which this can be addressed, whilst accepting that there have been efforts made to date. Avery Lodge DS0000028591.V301428.R01.S.doc Version 5.2 Page 16 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 The judgement of quality outcomes for this group of standards is adequate and would have been good with a more settled staffing situation and evidence of POVA first checks forming part of the employment process. EVIDENCE: On the day of inspection the service was staffed to meet the needs of those cared for. From discussion with staff and service users the inspector formed the opinion that in recent months there had been some difficulty in maintaining staffing, particularly with some staff who are no longer at the home proving unreliable. This was discussed with the provider who confirmed that there had been some difficulties, which the core staff team had helped to cover. It was confirmed that recruitment was taking place and that it was hoped to have full staffing in place in the near future. All of the care staff interviewed by the inspector felt that they worked in a good home and that it was well managed. All three had been at the service for a number of years and the inspector was told how well the home compared to other places they had worked. Service users spoken to praised the staff as hard working and felt that they were well cared for. The service exceeds government targets for NVQ level 2 care staff in employment and the provider should be commended for a positive commitment to staff training. The inspector tracked the employment process of the last person employed and whilst this was generally sound there was a lack of clarity as to when a POVA first check had been obtained and as such a requirement is made. Avery Lodge DS0000028591.V301428.R01.S.doc Version 5.2 Page 17 Avery Lodge DS0000028591.V301428.R01.S.doc Version 5.2 Page 18 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): 31,32,33,35,38 The quality outcome for this group of standards was adequate. With the resumption of normal management arrangements and the satisfactory addressing of outstanding issues then the service should achieve a good rating in this area. EVIDENCE: This inspection of the home took place over two days as the providers were unable to be present on the first day of inspection. The home is relatively small with the providers living on the premises and Mrs Hodgins normally providing the day to day management. However for understandable reasons, explained to the inspector, the past six months have seen the providers unable to offer their normal involvement. As such day to day control has passed to the deputy manager and whilst she has worked hard to hold the fort it has not been ideal and to a certain extent the home has marked time. It is understood that Avery Lodge DS0000028591.V301428.R01.S.doc Version 5.2 Page 19 normal management arrangements will soon be in place again and this will be beneficial for the service. It was confirmed to the inspector on the day that the providers do not get involved in the financial affairs of service users and as such no records were inspected in this area. The home holds investor in people status, which is due for reassessment this year. The inspector was shown good quality survey forms and told that this process of survey will be carried out when normal management arrangements are back in place. One of the provider’s is a moving and handling trainer and as such there is a good quality approach to this important area of health and safety. Avery Lodge DS0000028591.V301428.R01.S.doc Version 5.2 Page 20 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 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 x x x 3 x 2 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 x 3 x x 3 Avery Lodge DS0000028591.V301428.R01.S.doc Version 5.2 Page 21 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 OP29 Regulation 19 Requirement That the provider review recruitment practice to ensure that the system used is robust and that evidence can be provided of all staff having satisfactory references, POVA first and criminal record bureau checks. Timescale for action 31/07/06 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 OP9 Good Practice Recommendations That the provider store controlled drugs in a fully compliant cabinet. Avery Lodge DS0000028591.V301428.R01.S.doc Version 5.2 Page 22 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.V301428.R01.S.doc Version 5.2 Page 23 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!