Inspection on 24/05/07 for Avery Lodge

This inspection was carried out on 24th May 2007.

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 15/06/06

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 Unannounced Inspection 24th May 2007 09:20 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.V341647.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.V341647.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 Not applicable Care Home 13 Category(ies) of Old age, not falling within any other category registration, with number (13) of places Avery Lodge DS0000028591.V341647.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 15th June 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. The current weekly fee levels for the home are £285 to £334. Avery Lodge DS0000028591.V341647.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Care services are judged against outcome groups which assess how well a provider delivers outcomes for people using the service. The key inspection of this service has been carried out by using information from previous inspections, information from the providers ,the residents and their relatives, as well as others who work in the agency. This has included a recent unannounced visit to the agency and this report gives a brief overview of the service and current judgements for each outcome. What the service does well: What has improved since the last inspection? Since last inspected there has been some redecoration of bedrooms and the purchase of new beds. Staff have undertaken a number of training courses including new staff enrolling on NVQ training. Avery Lodge DS0000028591.V341647.R01.S.doc Version 5.2 Page 6 What they could do better: 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. Avery Lodge DS0000028591.V341647.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.V341647.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 Quality in this outcome area is good. That people admitted to the home can be confident their needs have been assessed and will be met by the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the site visit the Inspector looked at the services admission process and spent time tracking admissions with the service manager. As a result it was possible to see that the service ensures that pre admission assessment takes place and that care is taken to ensure appropriate admissions take place. The needs of current service users were considered in the context of the services category of registration. Whilst many of those accommodated have a variety of needs the Inspector is satisfied that at this time their needs are being met and their primary need for care is consistent with the services registration. Avery Lodge DS0000028591.V341647.R01.S.doc Version 5.2 Page 9 Avery Lodge DS0000028591.V341647.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): 7,8,9,10and 11 Quality in this outcome area is good. Residents enjoy good care where their health and personal care needs are met by caring and committed staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All of the written and spoken comment received by the Inspector showed that the care provided is highly valued. People feel they are treated with warmth, humour and kindness and that their privacy and dignity is protected. One visitor contrasted the energy of the approach with the sterility of the care received by their relative in a previous placement. Observation during the site visit confirmed this picture. Good day to day care recording takes place, however the main care plans were not being consistently maintained. The service enjoys good support from most health professionals. Care records and discussion with the manager indicated that peoples health care needs are well met. The management of medication is generally sound with sample Avery Lodge DS0000028591.V341647.R01.S.doc Version 5.2 Page 11 medication records accurately completed. It was noted that the service does not have a professionally produced register for controlled drugs and a recommendation in respect of this is made. Although staff administering medication have mostly had formal training it was noted that one person has not. There were no indications that this was resulting in problems, however it is recommended that formal training is undertaken. During the site visit the inspector was aware that staff and the proprietor were dealing with the expected death of a resident. From discussion with staff and family members who were visiting it was clear that a sensitive ,caring and supportive approach was being adopted at this difficult time. Avery Lodge DS0000028591.V341647.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 good. That residents enjoy a relaxed lifestyle where they can exercise choice and control and benefit from humour and stimulation. Visitors are welcomed and people enjoy tasty home cooking. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the site visit the Inspector experienced a warm and friendly atmosphere and observed residents to be relaxed and at home. Several visitors to the home took time to speak about their experiences and all commended the caring approach. People stated that the staff and management are approachable and that they are kept informed about their relatives. There was evidence of people enjoying a laugh and a joke and residents told the Inspector that they enjoyed the regular entertainment provided for them. Some relatives written comments expressed the desire for residents to be able to get out more and in the past the home was achieving this with more frequency. The service no longer has a mini bus which has contributed to this, however the Inspector would encourage the staff team to explore any Avery Lodge DS0000028591.V341647.R01.S.doc Version 5.2 Page 13 opportunities to get people out either individually or as a group. The feedback received about the food served was positive with residents liking the home cooking offered and aware that they could have a choice if they did not like what was provided. The service is managing some special dietary needs and in their last food hygiene inspection achieved 4 stars. Observation of food being prepared on the day showed it to look and smell appetising. Avery Lodge DS0000028591.V341647.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. Residents are confident that they could raise any concerns, confident in the knowledge that they would be properly addressed, however recording could be improved. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is no significant history of complaints attached to Avery Lodge. Discussion with the manager during the site visit indicated that there is a generally open approach to concerns, however the service is failing to maintain a written record of all complaints and a requirement is made in respect of this. Residents and visitors to the home told the Inspector that they would feel confident to raise concerns, but that they were very happy with the service and could not imagine complaining. Staff have received adult protection training and those spoken to felt confident that should they have any concerns about the care delivered then they would speak up. Avery Lodge DS0000028591.V341647.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. That residents benefit from a comfortable family style home which is clean and well maintained. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the site visit the Inspector toured the premises and sought the views of those visiting and living in the home. All of the above indicated that the home is a warm clean and comfortable place to live. The Inspector experienced no unwanted odour and the building was in good general order with no obvious health and safety hazards. Avery Lodge DS0000028591.V341647.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is adequate. That people living at the home benefit from a caring and committed staff team, who are able to meet their needs and are well trained. Current recruitment practice is, however, insufficiently robust to fully protect residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the site visit the Inspector talked to a number of staff members all of whom felt there was a strong staff team working in the best interests of people cared for. Most had worked in other services and felt that this home compared very favourably with their previous experience. Service users talked to said that the staff were kind and had time for them, often sharing a laugh and a joke. The atmosphere in the home was found to be relaxed with easy and positive interaction between staff and residents. Written comment received from families and people living at the home reinforced the above picture and during his time in the home the Inspector spoke to a number of regular visitors all of whom were keen to stress what a good home they felt it was. Having looked at staff rotas and spoken to residents and staff, the inspector is satisfied that the home is staffed to allow the meeting of needs. The home meets government targets for NVQ qualified staff and staff have completed a number of other training courses. The proprietor is keen for staff to train and is Avery Lodge DS0000028591.V341647.R01.S.doc Version 5.2 Page 17 seeking to develop key senior staff who have been enrolled on a management development course. There was concern regarding recent staff recruitment with a failure to follow the homes recruitment process fully resulting in three staff not having a Criminal Records Bureau check. This is a potentially serious issue although the Inspector is satisfied that residents have not suffered any harm as a result. Discussion with the proprietor during the site visit would indicate that this issue is related to a number of others where management functions have suffered as a result of the managers on going problems with her health. As a result of this the manager is going to alter her working pattern in order to concentrate on this and other areas in order that the homes good overall approach is not compromised. Given the above a requirement is made and the overall quality rating for this group of standards falls to adequate where it might reasonably have achieved a good rating. Avery Lodge DS0000028591.V341647.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35 and 38 Quality in this outcome area is adequate. That people living at the home benefit from a caring and committed manager, however some aspects of the management function have suffered as a result of ill health. This judgement has been made using available evidence including a visit to this service. Avery Lodge DS0000028591.V341647.R01.S.doc Version 5.2 Page 19 EVIDENCE: During the site the visit the Inspector talked to people living in the home, visitors, staff and the proprietor. It was clear from these discussions that the proprietor is both liked and respected by all concerned, however as at the last inspection, ill health has had an impact on the ability to fully deliver good outcomes in all of these areas. As such the services quality system has ceased to operate and formal staff supervision is suffering. In addition the reporting requirements resulting from Regulation 37 are not being fulfilled. These issues were discussed with the provider during the site visit and the Inspector was given assurances that these matters will be given priority and addressed. The service does not involve itself in the financial affairs of those it cares for and from records seen and discussion the service is maintaining a satisfactory approach to health and safety. Avery Lodge DS0000028591.V341647.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 x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 3 3 x x x x x x 3 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 2 x 3 x x 3 Avery Lodge DS0000028591.V341647.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? 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 Timescale for action 31/07/07 2 OP31 37 3 OP16 17 (2) 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. That the provider ensure that the 30/06/07 reporting arrangements as expected under Regulation 37 are fully complied with. That the provider ensure that a 30/06/07 record of all complaints is maintained. Avery Lodge DS0000028591.V341647.R01.S.doc Version 5.2 Page 22 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 OP9 OP9 OP7 OP12 Good Practice Recommendations That the provider record controlled drugs in a formal register. That all staff involved in administration of medication are in receipt of appropriate training. That care plans are regularly reviewed. That consideration is given as to ways in which residents may have more opportunities to occasionally get out of the home. Avery Lodge DS0000028591.V341647.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 Avery Lodge DS0000028591.V341647.R01.S.doc Version 5.2 Page 24 - 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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