Inspection on 22/03/07 for Avon Park

This inspection was carried out on 22nd March 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 Park 15/06/09

Avon Park 06/03/09

Avon Park 11/10/05

Avon Park 12/05/05

Avon Park 19/10/04

Avon Park 27/04/04

Avon Park 15/04/03

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

CARE HOMES FOR OLDER PEOPLE Avon Park 66 Southampton Road Park Gate Hampshire SO31 7AF Lead Inspector Ruth Burnham Key Unannounced Inspection 22nd March 2007 10:00 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 Park DS0000012244.V331012.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. Avon Park DS0000012244.V331012.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Avon Park Address 66 Southampton Road Park Gate Hampshire SO31 7AF 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) 01489 574616 Mr A Nethersole Mrs Nethersole Mrs Janine Patricia Haynes Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30), Physical disability over 65 years of age of places (10) Avon Park DS0000012244.V331012.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th October 2005 Brief Description of the Service: Avon Park is situated in a quiet residential area of Park Gate and is a short distance from the local shops and amenities. The home is set within its own grounds and has a large car parking area at the front of the home with attractive flowered borders. Accommodation is arranged over 2 floors with stair lifts between floors. The rear garden is wheelchair accessible and has a walkway with grab rails for service users, the garden is well maintained and mainly laid to lawn with trees shrubs and flowers. The home is registered with the Commission for Social Care Inspection for a maximum of 30 older people and older service users who have a physical disability. Fees range from 327 to 430 pounds per week. Avon Park DS0000012244.V331012.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector, who was in the home form 10 a.m. to 4 pm, carried out a site visit to Avon Park as part of the inspection process. During this time the inspector was able to speak with a number of residents around the home and had lunch with 3 residents in the dining room. Three members of staff, the manager and the owner were also spoken to, a number of records were examined and a tour of the premises was conducted. The visit was unannounced. On the day of the inspection the home’s manager and the registered provider assisted the inspector throughout the visit. Surveys were sent out to residents, health and social care professionals and relatives before the inspection. Responses received were positive. Interaction was observed between staff and residents throughout the inspection. The requirement made at the last inspection has been addressed by the home. There was 1 requirement and 1 recommendation made as a result of this inspection. What the service does well: What has improved since the last inspection? What they could do better: The registered person must ensure that; only people who fall within the category for which the home is registered shall be admitted unless the Commission has agreed to a variation to the conditions of registration. Shared rooms should be fit for purpose in that each resident should have equal access to light and ventilation and have their own clearly defined and private area. The home should be able to demonstrate that residents have made a positive choice to share. Avon Park DS0000012244.V331012.R01.S.doc Version 5.2 Page 6 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 Park DS0000012244.V331012.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 Avon Park DS0000012244.V331012.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): 1–6 Quality in this outcome area is adequate People who are considering moving into the home are provided with good information on which to make a judgement. Lack of early access to professional assessment may result in inappropriate admissions. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People who are considering moving into the home are provided with good information on which to base their decision. They are invited to visit the home and spend time with staff and the people who live there. There is a folder in reception area containing the service user guide and statement of purpose. Residents are provided with contracts. Avon Park DS0000012244.V331012.R01.S.doc Version 5.2 Page 9 There is an admissions procedure and people who have applied to move into the home are assessed by the manager in there own homes wherever possible. There have been recent admissions from hospital where there has been some confusion about healthcare needs. Delayed access to relevant healthcare documentation has meant that the manager has relied on verbal information provided by healthcare professionals. This has resulted in people being admitted to the home whose specialist needs may not be met. Staff do not have training in mental health or dementia care and the home is not registered to care for people with mental health difficulties. This was discussed with the manager and the owner during the visit. Both agreed to review recent admissions and ensure that the home only admits people who fall within the scope of their registration. Intermediate care is not provided in the home. Avon Park DS0000012244.V331012.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 – 11 Quality in this outcome area is good. People who live in the home are supported by a caring staff team. They can be confident that their needs will be met in a way that promotes their privacy and dignity who promote their privacy and dignity. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People who live in the home can be confident that their needs will be met in a way that promotes their privacy and dignity. Residents spoken to and contacted via the survey said that staff and management are friendly and kind. ‘Nothing is too much trouble’. ‘ The care is very good.’ ‘ They are always willing to help me.’ A number of care plans were examined, Not all needs were recorded however staff spoken to knew the residents well and knew their individual needs and preferences. Discussion took place with the manager Avon Park DS0000012244.V331012.R01.S.doc Version 5.2 Page 11 about how to develop and expand care plans and risk assessments to ensure that clear guidance about how each residents likes their care to be provided is recorded. People who live in the home sign their own care plans to provide evidence that they are consulted and involved in the care planning process. People who live in the home are protected through safe handling of medication. The home uses a monitored dose system for medication and there are appropriate policies and procedures in place. People who live in the home have their health care needs. Records show that they are provided with access to a range of health care professionals including GPs, district nurses, chiropodists etc. Service users are registered with a number of different GP’s in the local area and dental checks are carried out at local surgeries. Residents spoken to and surveyed all confirmed that they are treated with dignity and respect. Interaction observed between staff, the manager and residents was warm and supportive. Avon Park DS0000012244.V331012.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 - 15 Quality in this outcome area is good. People who live in the home benefit from the opportunity to take part in a range of activities. They are involved in the decision making processes of the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People who live in the home enjoy the opportunity to take part in a range of activities, these include bingo, puzzles, films, reminiscence sessions, music for health, craft sessions and regular outings. Residents told us how much they had enjoyed the special dinner on the previous evening in celebration of the first day of spring. They also said they enjoyed regular visits from entertainers. Those who wish to are able to join in regular church services and there are good links with the local community. People who live in the home are supported to maintain contact with family and friends. There is a notice in the entrance hall at the home, which gives clear Avon Park DS0000012244.V331012.R01.S.doc Version 5.2 Page 13 information about visiting, there are no restrictions but visitors are asked to respect meal times and all visitors are required to sign the visitor’s book. Residents who were spoken to or responded to the survey confirmed that routines in the home are flexible and they are able to live their lives as they choose. They told us that there had been a residents meeting in the previous week in which they had been invited to make suggestions or offer comment. Residents enjoy good home-cooked food that is well presented and served in comfortable surroundings. The home keeps appropriate records about the food provided and operates a four-week rolling menu, which is changed regularly. Staff were observed consulting residents about the choices available and all service users spoken to said that the food was very good and that portions were ample. Avon Park DS0000012244.V331012.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– 18 Quality in this outcome area is good. People who live in the home feel free to offer comment or complaints. There rights are upheld and they are protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People who live in the home are free to offer comment or complaint. There is a clear complaints procedure and records are kept of all complaints with evidence of investigation and response within reasonable timeframes. A recent complaint has resulted in adjustment to one of the home’s policies. Residents spoken to were confident about raising any concerns they may have and stated that they would address any complaint they may have to a staff member or to the homes manager. Those spoken to during the inspection said they had no complaints to make and were very happy with the service. Staff members spoken to were aware of the complaints procedure The rights of people who live in the home are protected, there is information in the home with regard to legal advice and independent advocacy and all of the service users are on the electoral roll. Residents are protected from abuse through clear policies and procedures. The manager said that staff have Avon Park DS0000012244.V331012.R01.S.doc Version 5.2 Page 15 received training on adult protection and the home has a whistle blowing policy and also a copy of the Hampshire Adult Protection procedure. Avon Park DS0000012244.V331012.R01.S.doc Version 5.2 Page 16 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 Quality in this outcome area is good. People who live in the home benefit from the comfortable and homely environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People who live in the home enjoy comfortable and safe surroundings. They have access to safe and comfortable indoor and outdoor communal facilities. Their private accommodation is furnished and equipped to ensure comfort and independence. The premises are homely and decorated to a good standard. Avon Park DS0000012244.V331012.R01.S.doc Version 5.2 Page 17 Individual bedrooms are safe and comfortable and resident are able to bring their personal possessions with them. There are 2 shared rooms. Discussion took place about the suitability of one of these rooms for sharing as the room is long and narrow. This means that one resident has limited access to natural light and ventilation, also her privacy is compromised. The provider agreed to review the use of this room as a shared room in the future. There are sufficient and suitable lavatories and washing facilities, all rooms have ensuite facilities. People who have mobility problems have access to specialist equipment to maximise independence. The home was clean and pleasant throughout. People who live in the home benefit from the well equipped laundry. Avon Park DS0000012244.V331012.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 - 30 Quality in this outcome area is good. People who live in the home benefit from the support of a committed, enthusiastic and well trained staff team. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People who live in the home benefit from the support of a committed and enthusiastic staff team. Rotas show that there are sufficient numbers of skilled staff on duty at all times to meet residents’ needs. Records were examined which show that residents are protected through sound recruitment policies and procedures which include taking up 2 written references and carrying out checks with Criminal Records Bureau before appointment. Staff receive appropriate training to enable them to care for residents effectively, including opportunity to undertake National Vocational qualifications. Avon Park DS0000012244.V331012.R01.S.doc Version 5.2 Page 19 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 – 38 Quality in this outcome area is good. The home is well managed and run in the best interest of the people who live there. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People who live in the home benefit from the leadership of the experienced, dedicated and well qualified manager. The manager been at the home for 18 years, 15 as manager, she has completed NVQ4 and the registered managers award. Residents spoken to said that the manager works very hard and is always ready to listen to them. Avon Park DS0000012244.V331012.R01.S.doc Version 5.2 Page 20 The security of people who live in the home is safeguarded. There was a copy of the homes employers liability insurance displayed in the hall of the home and the home’s accounts are audited annually. Residents are able to control their own finances as much as possible with the help of relatives and friends. The home manages small amounts of money for a few of the residents, appropriate records and receipts are kept, balances for 2 service users were checked and were correct. Regular safety checks are carried out on all equipment and installations. The manager has carried out a fire safety risk assessment, which is being submitted to the fire safety officer for approval. The home is run in the best interests of and in consultation with residents. Regular staff and residents’ meetings are held. The home has a quality assurance system, which includes regular consultation with residents through one to one contact and surveys. There is a comments book in the entrance lobby to the home, which enables visitors to inform the management on how well it is meeting its aims and objectives. Staff members spoken to confirmed that they receive regular supervision and that annual appraisals are carried out. Records are stored securely when not in use to protect the confidentiality of residents, those seen were clear, accurate and up to date. People who live in the home are protected from harm through safe working practices and clear policies and procedures. Avon Park DS0000012244.V331012.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 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 3 17 3 18 3 3 3 3 3 2 3 3 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 3 3 3 3 3 3 3 Avon Park DS0000012244.V331012.R01.S.doc Version 5.2 Page 22 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 OP3 Regulation 14 Requirement The registered person shall not provide accommodation to a service user at the care home unless, so far as it shall have been practicable to do so, needs of the service user have been assessed by a suitably qualified or suitably trained person; in that only people who fall within the category for which the home is registered shall be admitted unless the Commission has agreed to a variation to the conditions of registration. Timescale for action 30/04/07 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 Avon Park Refer to Standard OP23 Good Practice Recommendations Shared rooms should be fit for purpose in that each DS0000012244.V331012.R01.S.doc Version 5.2 Page 23 resident should have equal access to light and ventilation and have their own clearly defined and private area. The home should be able to demonstrate that residents have made a positive choice to share. Avon Park DS0000012244.V331012.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Park DS0000012244.V331012.R01.S.doc Version 5.2 Page 25 - 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!