CARE HOMES FOR OLDER PEOPLE
Avery Lodge 93 Southtown Road Great Yarmouth Norfolk NR31 0JX Lead Inspector
Hilda Stephenson Unannounced 9 May 2005 10.00am 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 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 I55 S28591 Avery Lodge V225996 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Avery Lodge Address 93 Southtown Road Great Yarmouth Norfolk NR31 0JX 01493 652566 01493 603627 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Karl Michael Hodgins Mrs Sheryl Anne Hodgins Mrs Sheryl Anne Hodgins Care Home 13 Category(ies) of Old Age (13) registration, with number of places Avery Lodge I55 S28591 Avery Lodge V225996 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Thirteen (13) Older People of either sex may be accommodated. 2. One (1) Service Users who is under the age of 65 years and is named in the Commissions records may be accommodated. 3. Total number not to exceed 13. Date of last inspection 13 December 2004 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 I55 S28591 Avery Lodge V225996 Stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection took place over three and a half hours as an unannounced inspection during the morning and lunch time period. A partial tour of the premises took place, policies and procedures, staff records and residents care plans were examined during this visit. Eight of the twelve residents, and one resident who was attending for day care and all of the five staff on duty were spoken to. The residents were well presented and sitting in a variety of the lounges, several visitors were seen during the morning. The home was clean and tidy with no unpleasant odour. What the service does well:
The home has a small loyal well-trained staff team that have worked at the home for several years. They take time to help new residents to settle in and assist those residents who attend the home during the day. There are organised activities arranged during the day with suggestions from residents taking priority. One resident explained how the proprietor had assisted them to obtain drawing materials so they could continue to enjoy this hobby. Several outings and parties are arranged during the year. One resident stated ‘I enjoy singing along with the karaoke, and its great fun when the staff join in’. The home offers a wide variety of food with the chef including suggestions from the residents, changing the menu every four weeks taking into account the seasonal choice of fruit and vegetables. The home both internal and external is very well decorated with a pleasant seating area situated at the front overlooking the fishpond. The home has achieved the ‘Investor’s in People’ standard. Avery Lodge I55 S28591 Avery Lodge V225996 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? 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. Avery Lodge I55 S28591 Avery Lodge V225996 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Avery Lodge I55 S28591 Avery Lodge V225996 Stage 4.doc Version 1.30 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 standard(s) 1,2,3,4,5,6 Detailed written information is provided for new residents. Each resident newly admitted has an assessment undertaken by the proprietor. EVIDENCE: Several care plans were examined taking into account the initial assessment visit undertaken by the proprietor. Each resident is given a copy of their terms and conditions including the fees expected as well as the services offered. A welcome pack containing the written details of the facilities and services provided by the home are given to each resident, an extra copy is left in the hallway, with the latest inspection report. The proprietor invites all prospective residents to visit and either stay for a short time or lunch. One resident stated ‘I came for my lunch and stayed for the rest of the day because there was a musical afternoon going on the day I visited’. Avery Lodge I55 S28591 Avery Lodge V225996 Stage 4.doc Version 1.30 Page 9 The care records confirmed that a review of care needs is carried out after the initial trial period, when relatives and a social worker are invited to speak with the resident to help them make up there minds to stay at the home and to ensure that the home can meet their individual needs. The proprietor confirmed that residents have been admitted on an emergency basis although an assessment is usually obtained beforehand. Avery Lodge I55 S28591 Avery Lodge V225996 Stage 4.doc Version 1.30 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 standard(s) 7,8,10,11 Care plans and health needs of each resident are identified, reviewed and are met by knowledgeable staff who have a good understanding of their needs. EVIDENCE: Three care plans were seen with each one containing detailed personal care, health needs and social interests. Two residents having records showing that they receive visits from a specialist professional every two weeks. The proprietor involves each resident with their written care plan and if they are too frail a close relative is invited to assist with the residents wishes. The home has had an occasional death of a resident, with details of their wishes having been obtained beforehand. Several written letters to the home confirmed that staff offers support for both those who are dying and their relatives. One resident stated ‘I get up when I wake up, the staff don’t come in until I ring for help which is my wish, and I go to bed quite late, the staff are extremely good to me’. Avery Lodge I55 S28591 Avery Lodge V225996 Stage 4.doc Version 1.30 Page 11 It was observed that the staff treat each resident with respect escorting them to their room if the GP or Nurse visits. Avery Lodge I55 S28591 Avery Lodge V225996 Stage 4.doc Version 1.30 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 standard(s) 12,13,14,15 Social activities are well managed within the home taking into account individual interests and arranging social functions. EVIDENCE: One member of staff organises sociable activities ranging from karaoke musical afternoons, to include an entertainer who visits providing requests and encouraging residents to take part. The home has a large screen television in the main lounge and arranges film afternoons with a wide selection of films from musicals to war with a selection of modern films. Both televisions have satellite programmes provided. The home has its own library of books including large print and audio books. A selection of games, dominoes and cards are also provided with staff taking part. One resident stated ‘I enjoy going to my room to do my drawing’. Several residents are encouraged to continue with their own hobbies. Seasonal social events and birthdays are celebrated with a party within this home with staff attending with their families. Avery Lodge I55 S28591 Avery Lodge V225996 Stage 4.doc Version 1.30 Page 13 Residents confirmed they get a variety of meals and that the chef includes some of their suggestions on the menu. Every resident that commented about the food quoted that the quality and range was excellent. Avery Lodge I55 S28591 Avery Lodge V225996 Stage 4.doc Version 1.30 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 The home has a satisfactory complaints system in place with evidence that resident’s views are listened to and acted upon. EVIDENCE: The complaints procedure is displayed within the documents in the hall and is discussed with residents when they arrive at the home. The proprietor has a positive attitude regarding complaints in ensuring that any complaint can improve the service for the resident. Complaints are recorded with the action taken. No complaints have been logged since the last inspection. A resident stated ‘ I would speak to Sheryl if I had a complaint, although I am very happy here’. No complaints were received from either residents or visitors during this visit. Avery Lodge I55 S28591 Avery Lodge V225996 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,25,26 The standard of the décor is high and the home is clean and tidy. EVIDENCE: A tour of the ground floor and part of the first floor was undertaken. All areas seen were clean and tidy and free from any odour. During the past month each bedroom has been deep cleaned, with the bedrooms being decorated when they become vacant. The three lounge curtains were being cleaned during this visit. The bedrooms are situated on two floors with access to the first floor by a shaft lift. Two lounges have a television, reading material and music with comfortable seating and adequate tables and lighting. The third lounge is a quiet area and is generally used for those who wish to read or entertain visitors. The dining room is well laid out containing adequate seating to allow residents to have a sociable place for their meals.
Avery Lodge I55 S28591 Avery Lodge V225996 Stage 4.doc Version 1.30 Page 16 The outside area provides seating and a pergola for those who wish to smoke, overlooking a fishpond and flowerbeds. A barbecue area is also situated beside the patio. The front door has broken panes of glass on the stained glass window and should be replaced; there is no risk to the residents with one side having been fitted with safety glass. The personal laundry is provided by the home with adequate facilities. Avery Lodge I55 S28591 Avery Lodge V225996 Stage 4.doc Version 1.30 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28 Sufficient numbers of staff are on duty to meet residents’ needs, with extra staff brought in during busy periods. EVIDENCE: The usual number of staff on duty are two care staff with the proprietor during the day, supported by one domestic and one cook, reducing to two care staff in the evening. One member of staff is on duty overnight with the proprietor on call, who lives above the premises. Extra members of staff are brought in when social events and outings are arranged, or if a hospital appointment requires an escort. The home provides day care facilities to take up to three residents during the day with adequate staffing to care for their needs. From twelve care staff ten have achieved their NVQ level 2 training with a further four taking the NVQ level3 training to continue to develop the skills, which is exceptional good practice. Avery Lodge I55 S28591 Avery Lodge V225996 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,37,38 The home is well managed by the proprietor undertaking personal care, supervising staff and ensuring the health and safety of both staff and residents. EVIDENCE: The proprietor Sheryl Hodgins manages the home and lives on the premises. She continues to attend regular training and has commenced the Social Health Care Degree training modules. She continually supervises and encourages her staff team to develop their own skills as evidenced by the amount of staff who have achieved the NVQ training. The second proprietor Karl Hodgins is a health and safety teacher and maintains all the required checks to a high standard. Mandatory moving and handling, first aid, food hygiene, fire and infection control are up to date for all the staff team.
Avery Lodge I55 S28591 Avery Lodge V225996 Stage 4.doc Version 1.30 Page 19 The home has a regular fire procedure to follow with records to confirm this has taken place. Avery Lodge I55 S28591 Avery Lodge V225996 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 4
COMPLAINTS AND PROTECTION 3 3 x x x x 3 3 STAFFING Standard No Score 27 3 28 4 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 3 x x x x x 3 4 Avery Lodge I55 S28591 Avery Lodge V225996 Stage 4.doc Version 1.30 Page 21 No 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 19 Regulation 23 Requirement The broken panes of glass in the front door should be replaced. Timescale for action By 30/9/05 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 Good Practice Recommendations Avery Lodge I55 S28591 Avery Lodge V225996 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection 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
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