Inspection on 11/07/07 for Avon House

This inspection was carried out on 11th July 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

Avon House 25/06/08

Avon House 09/08/06

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Avon House Stockcroft Road Balcombe West Sussex RH17 6LG Lead Inspector Mrs S Gawley Unannounced Inspection 11th July 2007 09:30 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 Avon House DS0000066866.V340870.R02.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. Avon House DS0000066866.V340870.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Avon House Address Stockcroft Road Balcombe West Sussex RH17 6LG 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) 01444 811282 Avon House (Balcombe) Limited Mrs Veronica Vivien Freeman Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Avon House DS0000066866.V340870.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th August 2006 Brief Description of the Service: Avon House is a care home for up to 19 elderly residents over 65 years of age. The registered provider is Fresh Green Limited and the registered manager responsible for the day-to day running of the home is Veronica Freeman. The ownership of the home changed and the home was newly registered on 31st March 2006. The home is a large Edwardian property located in a pleasant residential road in the village of Balcombe in West Sussex, with local shops a short distance away. Resident’s accommodation is arranged on two floors with a passenger lift giving access to both floors. Accommodation consists of thirteen single and three double rooms all with ensuite facilities. There is a large dining/lounge area on the ground floor. The home is surrounded by a large rear and front garden both of which are accessible to residents. The fees charged range between £351 and £520 Avon House DS0000066866.V340870.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit as part of the inspection process was carried out on the11th July. The registered provider who is also the registered manager facilitated the inspection. Prior to the inspection all files held by the Commission were perused. The provider had submitted an Annual Quality Assurance Assessment, three surveys were received from residents and four surveys were received from relatives. Two relatives were spoken to on the phone and comments were received from two professionals. All of the comments received were positive. Many of the residents were spoken to on the day and all expressed satisfaction in all aspects of the care received. Three residents were case tracked and all aspects of their care were assessed. The majority of the outcomes of this inspection were assessed as good. What the service does well: What has improved since the last inspection? The home has been redecorated and refurnished. The sitting and dining room are now tastefully furnished and comfortable. Residents spoken to stated that Avon House DS0000066866.V340870.R02.S.doc Version 5.2 Page 6 there have been many improvements in the home since the new proprietor took over in March of last year. Care plans have been improved to show full assessment of all residents’ needs and interventions required to meet those needs. Residents are consulted regarding activities. Staff files have been improved and contain all the necessary documentation. A training programme for staff has been put in place. The home has been redecorated and refurnished. The sitting and dining room are now tastefully furnished and comfortable. Residents spoken to stated that there have been many improvements in the home since the new proprietor took over in March of last year. Fire equipment and utilities testing has been put in place. Quality assurance systems have been developed. 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. Avon House DS0000066866.V340870.R02.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 Avon House DS0000066866.V340870.R02.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 Standard 6 is not applicable People using this service experience good outcomes in this area because need is fully assessed prior to admission. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A pre admission assessment is completd by the Manager, in addition to any assessments or information provided by Social Services or hospitals and family. Evidence of these assessments were seen in care plans. A resident admitted during the past year confirmed he was satisfied with the admission process. All residents are invitied to visit the home prior to admission unless ill health prevents this. Avon House DS0000066866.V340870.R02.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7-10 Residents have a comprehensive plan of care documented. The resident’s health care needs are met. Medication is not safely stored and administered in the home. Resident’s privacy and dignity is respected and protected by the staff. People who use this service experience good outcomes because all needs are assessed and met and residents are treated with respect. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All Mental, physical, social, (including religious), nutrition, mobility, continence needs are recorded. Risk assessments are also recorded and all care plans are reviewed monthly. Residents spoken to confirmed that their needs are met in a timely and respectful manner. The requirement of the last inspection in relation to this is met. Avon House DS0000066866.V340870.R02.S.doc Version 5.2 Page 10 Residents confirmed that call bells are answered in a timely manner, “When the bell rings the staff come”. One resident stated that she sleeps poorly and frequently rings the bell and that staff always come and are helpful. It was also commented “It is excellent here”. A district Nurse spoken to on the telephone stated that she feels the care on offer is, that the establishment is homely and that she is called appropriately to the home. A relative spoken to on the telephone stated that the home was delightful and that his mother was very happy there. There are some shortfalls in the administration of medicines. It was evident from an entry in one care plan that Lactulose had been administered to a resident but there was not any prescription or supply of the drug in that resident’s name. Medicines must only be administered to the person for whom they have been prescribed, labelled and supplied. There is not a drug fridge in the home and one resident’s insulin is stored in the kitchen fridge. There is also not a lockable space in the resident’s bedroom for the insulin. . The controlled drug register is a loose-leaf book and it is the guidance of the Royal Pharmaceutical Society of Great Britain that a register is a hardbound book with numbered pages. These issues were discussed with the registered manager and are a requirement of this inspection. There is currently no photo identification of the residents on either the care plans or the Medicine Administration Charts. The manager has already purchased a digital cameras and it is her intention to photograph residents for their safety and protection. Avon House DS0000066866.V340870.R02.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12-15 The lifestyle offered in the home meets resident’s needs and preferences. Visitors are welcome and residents enjoy a varied diet. People who use this service experience good outcomes because the lifestyle offered in the home meets residents’ needs and preferences. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents are free to come and go and one resident visits a club in the village once weekly. Two residents attend church on Sunday. Communion is offered weekly in the home. The AQAA stated that an activities coordinator was employed three days a week offering a selection of activities. This has now been reduced to one day a week at the residents’ request. Residents spoken to confirmed this saying that they are happy to have her visit once a week. Residents confirmed that friends and relatives are encouraged and are offered refreshment or lunch. The home now has community involvement and the Avon House DS0000066866.V340870.R02.S.doc Version 5.2 Page 12 church choir have offered to visit. A pianist visits once monthly, the proprietor having bought a piano for the home. There are seasonal events such as Christmas Carols. There is currently not a cook and the registered manager or an extra carer fulfils this function. There is a menu in place but only that day’s selection is put on display. Residents spoken to stated that although the food is invariably good they are not routinely asked beforehand if they require a different choice. One resident who does not like fish is generally offered egg instead. The manager is actively recruiting a cook and may have one in the near future. She will address the issue of menu display and will post each weeks in the dining room in advance. The meal on offer today was that advertised, was well presented and was enjoyed by the residents. Staff were observed interacting respectfully with the residents at all times and residents spoken to confirmed this. Avon House DS0000066866.V340870.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Complaints are appropriately managed. Residents are fully protected from abuse. People who use this service experience good outcomes because complaints procedure is followed and suitably trained staff protect residents from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Complaints are recorded and are investigated within the published timescales. Complaints documentation inspected evidenced this. Residents and a professional spoken to stated that they could complain or express concern about any matter and it would be dealt with quickly. West Sussex adult protection procedures are in place and staff demonstrated an awareness of these. Adult protection is also included in some planned training for this summer. The District Nurse spoken to stated that she had not ever seen behaviour of concern in the home. Avon House DS0000066866.V340870.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Residents live in a mostly safe, clean and well-maintained environment. People who use this service experience adequate outcomes, as the home is well maintained but has shortfalls in the arrangements for the containment of fire. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home on this occasion was clean and neat and from offensive odour. The sitting room and dining area were attractive and welcoming with fresh flowers. There are accessible well-maintained grounds. The home was tastefully furnished throughout. Avon House DS0000066866.V340870.R02.S.doc Version 5.2 Page 15 A relative spoken to on the telephone stated that the new proprietor manager has transformed the home and that is in newly decorated and refurnished. This confirmed what was stated on the AQAA. There are two bathrooms but one with assisted bath and the other is currently used for storage. The need for both bathrooms to be in use was discussed with the manager and she will add this to her plans for improvement, which includes continuing decoration and further work to the garden to make it more level. Residents’ rooms are personalised. There are not locks on doors and the manager stated that residents do not at this time wish to lock their doors. Residents spoken to in the lounge confirmed this. The manager confirmed that locks would be put on doors as part of the decoration to allow residents the choice. Documentation was seen on fire equipment and utilities testing Two fire doors were wedged open and the need for this practice to cease was discussed with the registered manager. This is a requirement of this inspection Avon House DS0000066866.V340870.R02.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): 27-29 Residents are protected by the homes recruitment policies and procedures and by an induction and training programme. People who use this service experience good outcomes because a suitably recruited and trained staff meets their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff rota showed the registered manager with two carers on duty. A further carer was in the kitchen cooking the lunch as there is not a permanent cook at present. There is not a domestic staff at present and the carers do these duties in the afternoon when the residents are resting. The residents did not appear to be negatively impacted by this arrangement at present but the need for suitable kitchen and domestic staff to be in place was discussed with the manager, so that the carers do not have leave their caring duties to complete domestic tasks. She stated that she is in the process of recruiting. Avon House DS0000066866.V340870.R02.S.doc Version 5.2 Page 17 Staff files inspected contained all the required documentation and staff spoken to confirmed induction, training and supervision and demonstrated knowledge of adult protection procedures. Avon House DS0000066866.V340870.R02.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): 31,33,35,38 Residents and staff benefit from experienced management. The home is run in their best interests. Financial interests are safeguarded and the health safety and welfare are mostly protected. Quality assurance procedures are in place and are being further developed. People who use this service experience good outcomes as the home is well managed and is run in their best interests. This judgement has been made using available evidence including a visit to this service. Avon House DS0000066866.V340870.R02.S.doc Version 5.2 Page 19 EVIDENCE: The home is run by a suitably qualified and experienced manager. Residents spoken to feel the home is well run and feel happy there. A district nurse spoken to stated that she feels the home is well managed and that she is called out appropriately. Quality assurance systems have been put in place in the form of residents and relatives surveys and residents meetings are held six monthly. The home holds money for two residents and this is stored and recorded appropriately. Mandatory training has been put in place and staff confirmed that they are receiving this. There is ongoing maintenance and redecoration and there was documentary evidence of utilities maintenance. The requirement of the last inspection report that fire equipment testing be put in place has been met and documentary evidence of this was seen. Fire doors, however, were wedged open and it is a requirement of this inspection that this matter be addressed. Avon House DS0000066866.V340870.R02.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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Avon House DS0000066866.V340870.R02.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 OP9 Regulation 13,17 Requirement The registered person ensures that there is a policy and staff adhere to the procedures for the recording, storage and administration and service users are able to take responsibility for their own medication if they wish, within a risk management framework. All fire doors must be kept closed unless held open by a device, which meets the guidance of the fire service. Timescale for action 20/09/07 2 OP19 23 20/09/07 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 OP7 Good Practice Recommendations Residents ‘ plans of care to include a photograph as specified in regulation 17, Schedule 3. Avon House DS0000066866.V340870.R02.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Avon House DS0000066866.V340870.R02.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. 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