Inspection on 08/05/08 for Avery Lodge

This inspection was carried out on 8th May 2008.

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

Other inspections for this house

Avery Lodge 20/08/09

Avery Lodge 05/05/09

Avery Lodge 24/05/07

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 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Avery Lodge 93 Southtown Road Great Yarmouth Norfolk NR31 0JX Lead Inspector Mr Pearson Clarke Unannounced Inspection 8th May 2008 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.V364589.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.V364589.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.V364589.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 24th May 2007 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.V364589.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means that people who use the service experience adequate quality outcomes. 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 or visit the home. This has included a recent unannounced visit to the home and this report gives a brief overview of the service and current judgements for each outcome. During the site visit the inspector spent time with service users both in a group and on an individual basis and views expressed have helped shape the judgements made. In addition time was spent observing life in the home and staff on duty were spoken to, as was the service manager. A tour of the premises was undertaken and relevant records were inspected. What the service does well: The home’s staff team enjoy their jobs and this results in residents benefiting from their happy and committed manner. The day to day atmosphere within the home is relaxed with much evidence of kindness and humour. People are treated as individuals and residents could detail ways in which the management and staff had improved their quality of life. Survey evidence received from relatives, friends and residents included comments such as “ I intend to move in here when my time comes”, “ it’s a homely loving place staff are concerned over small details”, “ They are always ready to have a laugh or song with you”, “ they are friendly and caring and always have time to stop and chat, its not just a job to them”. The home is kept clean and free of odour. The service meets government targets for staff achieving National Vocational Qualifications, which helps ensure that residents benefit from staff who have been trained to do their jobs. Avery Lodge DS0000028591.V364589.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The provider must ensure that management systems and records are consistently maintained. Important areas include ensuring a safe employment system and the need to notify the commission of significant issues as defined by Regulation 37. In respect of the employment system the provider must ensure that all employees have necessary pre employment checks and that staff records are easily accessible and clearly demonstrate that references have been obtained and the necessary criminal records bureau check has been carried out. This helps to ensure the safety of residents. A number of policies and procedures are lacking in detail and need revision. These include the complaints process, which needs more detail as to how to complain, the process of investigation and the timescales for dealing with complaints. Any complaints raised must be properly recorded and that record must be available for inspection. The service’s medication policy needs to provide detailed guidance for staff in order to help ensure a consistent approach and therefore contributing to staff giving residents their medication in a safe and appropriate manner. The home’s service user guide does not provide the necessary information to enable prospective and existing residents to understand what they can expect from the care home. Whilst their was no evidence that people did not understand what their entitlements were and how the home runs, this information was largely gained through discussion and a clear written guide will help prevent misunderstanding and reinforce the informal process. Records of all training provided to staff should be maintained and used to help ensure that people have received the training they need to carry out their jobs. The provider needs to ensure consistent and stable management arrangements are maintained to help ensure continued good care for those who live there. Avery Lodge DS0000028591.V364589.R01.S.doc Version 5.2 Page 7 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.V364589.R01.S.doc Version 5.2 Page 8 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.V364589.R01.S.doc Version 5.2 Page 9 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): Quality in this outcome area is ( adequate ). Prospective residents are provided with the care they need based on an appropriate assessment, however the written information available at the point of admission does not fully inform them about the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the site visit it was apparent that the main means of communication of information about the home was via the main notice board, where notices and the home’s statement of purpose/service user guide is displayed. Discussion took place with the home’s management about the service user guide and its usage and content. As such it was apparent that the current document does not contain all of the specified content as required by regulation. Four existing residents were spoken to and all were confident that they understood how the home runs and what they are entitled to, however the Avery Lodge DS0000028591.V364589.R01.S.doc Version 5.2 Page 10 manager confirmed that it is not current practice to give existing and prospective residents a copy of the service user guide. Two of the residents most recently admitted had their admission process tracked. Both told that they had been visited by the proprietor prior to admission and that they had described to them what the home could offer and were encouraged to give information about their needs and wishes. In both cases they were very positive about how the home’s staff had met those needs and improved their quality of life. Records seen contained professional social work assessments supported by the service’s own assessment documentation. Avery Lodge DS0000028591.V364589.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is ( good). That people receive good care based on a written plan of care and supported by good quality day to day interventions, which have enhanced peoples quality of life. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the site visit a selection of care records were inspected. The care plans seen were better structured than found at the last visit and, as such, the information was more accessible. Staff spoken to, were aware of the plans and the role that they play in the delivery of care to each individual. Each plan allowed for the tracking of people’s health care needs and how they were being met and contained information about people’s past histories. Risk assessments were in place and there was evidence of review. Avery Lodge DS0000028591.V364589.R01.S.doc Version 5.2 Page 12 The arrangements for the management of people’s medication were looked at. As such medication was securely stored and those medicine administration records seen, were accurately completed. The manager confirmed that all staff who give out medicines have received training, although there were no records available to support this. Controlled drugs were appropriately stored and recording was being made in a compliant register. The homes medication policy was seen and found to be lacking in detail, which increases the potential for mistakes and the possibility of inconsistency of approach. All of the residents spoken to at the site visit were extremely positive about the care given to them and this was consistent with written comment received in advance of the visit. Comments were made such as “its lovely I would not go anywhere else” and “ the best place I have ever been”. Two of the people spoken to were able to clearly describe how much their quality of life had improved since admission. From discussion with the manager and records seen, it was clear how in one case the provider had instigated medical intervention to allow for the proper diagnosis of a longstanding misdiagnosed condition and in another huge effort was made to track down and reacquaint a resident with a pet previously removed from the person concerned. Avery Lodge DS0000028591.V364589.R01.S.doc Version 5.2 Page 13 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 people enjoy a relaxed lifestyle where they enjoy good food and feel able to exercise choice and control over their lives. This judgement has been made using available evidence including a visit to this service. EVIDENCE: From discussion with residents, staff and the provider it was clear that people enjoy a relaxed lifestyle. Observation during the site visit confirmed that staff see sitting, talking and sharing a joke with residents as an important part of their role. Activities, such as cards, quizzes and music are often spontaneously instigated by staff, and residents spoke of how friendly everyone is. Residents said that there is regular entertainment, which they enjoy. Written feedback from relatives was very positive, for instance “ There is always a light, bright atmosphere in the home “ and “it’s a homely loving place, staff are concerned over small details “. Residents said that they felt free to spend their time as they wished and to choose their routine. All of those spoken to said that the food was very good and one relative commented “I Avery Lodge DS0000028591.V364589.R01.S.doc Version 5.2 Page 14 have seen the food and it always looks tasty and hot” whilst another stated “my mother is on a gluten free diet and they are very good at looking for new products“. During the site visit residents were observed requesting that a salad be served as the weather was hot, and this request was positively received and clearly not a problem. Avery Lodge DS0000028591.V364589.R01.S.doc Version 5.2 Page 15 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). That the services general approach to safeguarding helps to ensure the safety of residents, although improved policy, procedure and recording in this area is needed to assure consistency. This judgement has been made using available evidence including a visit to this service. EVIDENCE: From discussion with staff and management it was clear that there was an understanding of safeguarding and it was confirmed that staff have received training in this area with further training booked for the summer months. Staff members were clear about the importance of reporting any concerns and who they would report to. Staff were aware of the home’s policy in this respect, however this policy lacks detail particularly in relation to the agencies involved in safeguarding and how and when to contact them. The Commission is aware of one complaint made to the provider since last inspected and this was discussed with the provider. Whilst aware of the issues the provider had no record of the complaint or of its outcome. The complaints policy was seen and whilst clear about peoples right to complain, it lacked detail as the process to be followed and the timescales for dealing with the complaint. Residents spoken to said that they felt safe and that they could Avery Lodge DS0000028591.V364589.R01.S.doc Version 5.2 Page 16 think of no reason to complain, however should they do so they would speak to the owners and felt sure their complaints would be addressed. Avery Lodge DS0000028591.V364589.R01.S.doc Version 5.2 Page 17 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 people benefit from comfortable, clean accommodation, which is well maintained. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the site visit a tour of the building was made with the manager. Areas of redecoration were seen and all areas seen were clean and fresh with no unwanted odour. Residents spoken to confirmed that this was how it always was and that they liked their rooms. Survey evidence supported this with comments such as “ the home never smells”. Avery Lodge DS0000028591.V364589.R01.S.doc Version 5.2 Page 18 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 residents benefit from well trained, kindly and motivated staff, however the current recruitment practice increases the risks to those living at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: From observation, discussion with staff, management, residents and records seen at the site visit it is clear that the home is staffed to meet the needs of those accommodated. Staff spoken to, were keen to stress that they felt they worked in a good home, providing good care. For instance one written comment received said “ I think this is a perfect environment for residents and a joy to work in”. As such contrast was made with some other homes that people had worked in. Likewise the comment received from residents and families was very positive in its tone. The manager confirmed that there is a commitment to training staff and information submitted to the Commission showed that 50 of the staff have NVQ level 2 or above with the remaining 50 working towards it. There were, however, no records maintained within the home to confirm this. Staff records were tracked for recent appointments and once again the provider was failing to ensure a safe system of employment, where all Avery Lodge DS0000028591.V364589.R01.S.doc Version 5.2 Page 19 necessary checks and reference were undertaken prior to the commencement of work in the home. Avery Lodge DS0000028591.V364589.R01.S.doc Version 5.2 Page 20 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): 31,33,35 and 38 Quality in this outcome area is (adequate ). That the managers approach to staff and residents is positive, however failure to carryout management functions is potentially undermining the running of the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: It was clear from discussion with the provider and from the views of residents and staff that the management of day to day care is effective. As such interventions by the manager could be tracked and shown to have a positive impact on the lives of residents. People spoken to were very positive about the owners of the home , seeing them as kindly, approachable and committed to their best interests. The Avery Lodge DS0000028591.V364589.R01.S.doc Version 5.2 Page 21 service has experienced a difficult period in relation to finance and the commission is aware that all staff chose to remain at the home, demonstrating loyalty and commitment. Staff also said that they felt supported in their roles. However during the site visit it became apparent that a number of management functions were still not being maintained as they should be. As such employment records were unsatisfactory, there was a failure to fulfil the notification obligations to the commission as required by regulation and the home’s quality system is not being maintained. The Annual Quality Assurance Assessment submitted lacked detail and a number of the service’s policies including complaints and medication are not satisfactory. Discussion with the provider indicated that external events relating to finance and health are still impacting upon the ability to manage the home effectively, however the provider said that an appointment has been made for a person to work alongside her and to undertake the registered managers award. Records seen indicate that the service has an appropriate approach to health and safety Avery Lodge DS0000028591.V364589.R01.S.doc Version 5.2 Page 22 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 2 x 3 x x 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 2 17 x 18 3 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 3 x 3 x x 3 Avery Lodge DS0000028591.V364589.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 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, in order to provide protection to residents. Repeat Requirement Timescale for action 30/06/08 2. OP31 37 3. OP16 17 (2) That the provider ensure that the 30/06/08 reporting arrangements as expected under Regulation 37 are fully complied with, so as the commission can monitor the welfare of residents. Repeat Requirement That the provider ensure that a 30/06/08 record of all complaints is maintained, in order to demonstrate that complaints are being addressed in a satisfactory manner. Repeat Requirement 30/08/08 4 OP1 5 (1) a b c That the services service user d e f (2) guide be revised to ensure that its content and usage complies DS0000028591.V364589.R01.S.doc Avery Lodge Version 5.2 Page 24 5 OP9 13 (2) 6 OP16 22 (1) (2) (3) (4) (5) (7) with regulation in order to ensure that people have the necessary information about the home. That the provider revise the 30/08/08 homes medication policy to ensure that it provides clear and comprehensive guidance as to the arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines, in order to help ensure the safety of residents. That the provider revise the 30/08/08 complaints procedure in line with regulation to ensure that people have a clear understanding how to complain and the process that will be followed. 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 OP28 Good Practice Recommendations That the provider maintain a record of all staff training in order to demonstrate that necessary training has been provided. Avery Lodge DS0000028591.V364589.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Eastern Region Eastern Regional Contact Team CPC1 Capital Park Fulbourn Cambridge CB21 5XE 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.V364589.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!