Inspection on 01/11/05 for Avondale

This inspection was carried out on 1st November 2005.

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

Avondale 17/07/08

Avondale 06/08/06

Avondale 20/05/05

Avondale 29/03/05

Avondale 13/04/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Avondale 152 New Lane Eccles Manchester M30 7JB Lead Inspector Judith Morton Unannounced Inspection 1st November 2005 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 Avondale DS0000006694.V257237.R01.S.doc Version 5.0 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. Avondale DS0000006694.V257237.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Avondale Address 152 New Lane Eccles Manchester M30 7JB 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) 0161 707 2303 0161 707 9153 Focus Care Centres Ltd Mrs Ayoka Olabisi Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36) of places Avondale DS0000006694.V257237.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. Up to 36 service users requiring nursing or personal care may be accommodated. One named service user who is under 65 years of age and requires personal care may be accommodated. One named service user who is under 65 years of age and requires nursing care may be accommodated Minimum nursing staffing levels as specified in the Notice issued under Section 25(3) of the Registered Homes Act 1984 shall be maintained. Staffing levels as specified in the Residential Forum for Staffing in Care Homes for Older People for service users receiving personal care only shall be maintained. The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 29th March 2005 6. Date of last inspection Brief Description of the Service: Avondale provides nursing and personal care for up to 36 elderly service users. The detached premises consist of an older house together with a recent extension. The building is set back from a main road close to shops and public transport; there is a car park to the front and gardens and a patio area to the rear. Accommodation is split over two floors and is comprised of 16 single occupancy and ten double occupancy rooms. The main lounge/dining areas are on the ground floor and a smaller lounge is situated on the first floor. There is a passenger lift to the first floor. Avondale DS0000006694.V257237.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 6 hours. The manager was on duty. Five residents, two visitors, four care staff, the cook, the maintenance man and a young person on work experience were all spoken with during the inspection. Four files were reviewed, two residential and two nursing files. Three staff files were also reviewed. What the service does well: 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. Avondale DS0000006694.V257237.R01.S.doc Version 5.0 Page 6 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 Avondale DS0000006694.V257237.R01.S.doc Version 5.0 Page 7 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 the following standard(s): 1, 2, 3, 4 & 5 There is sufficient information available for residents and potential residents to know what services are provided at Avondale and how well these would meet their needs. EVIDENCE: The statement of purpose and service user guide were two separate documents. They both contained sufficient information available for residents, and potential residents, to know what services are provided at Avondale and how well these would meet their needs. Each was produced in a large, bold print and these were held as the master copies for photocopying should they be required. There was also a copy of the findings of the last inspection produced in large bold print. Avondale DS0000006694.V257237.R01.S.doc Version 5.0 Page 8 The manager said she would visit potential residents to conduct an assessment of her own to ensure Avondale could meet their needs. These assessments were seen on all of the files viewed. One visitor spoken with said that she had been fully involved in the assessment, as her husband was unable to contribute verbally. Prospective residents and their families are free to visit Avondale before making a decision so that they can assess the suitability of the home. One of the relatives spoken with confirmed that she had visited a number of homes, including Avondale before making a decision for this to be the new home for her husband. Avondale DS0000006694.V257237.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 & 11 The detail in the care plans will make sure that all staff know how they should meet the resident’s needs and ensure that their needs are met. The staff would know how well they are meeting the residents’ needs and wishes if they consulted with them before writing the daily record. EVIDENCE: All of the files reviewed contained a detailed care plan, which had been drawn up from information gained during the assessment. Both the assessment and care plans had been completed with, and were signed by, the resident and/or their family. The care plans were reviewed regularly and changes were made where necessary. The manager had devised a sample file for staff to follow when making up a new file for a resident so that they can be certain they are including all the documentation required. Additionally, each file contained a document called, ‘getting to know you’. This gave the reader an insight into the past life of the resident as it described their Avondale DS0000006694.V257237.R01.S.doc Version 5.0 Page 10 family, hobbies and past work. This information would give staff topics for discussion with the resident and help in planning suitable activities. One of the documents had only partly been completed as the staff member had written, ‘resident not willing to discuss’. This statement should be dated as the situation may have changed now that the resident is more settled. Alternatively, further information may have been gathered through conversation. The document should be continually added to until it is completed. (See recommendation 1) The daily recordings were being completed and, on the whole, reflected how the needs of each resident had been met. However, the GP had visited one resident and said that she must have her legs elevated whenever possible. It was not recorded at all that this had been done. Also the same resident was known to leave the table before finishing any meal and she was in danger of losing weight. Staff were instructed to encourage her to remain at the table to finish her meal. There were no recordings in relation to meal times throughout her daily records. (See requirement 1) The daily recordings did not contain any evidence that the resident’s view of how well they felt their care had been delivered. There should be some consultation with each resident and their comment should be recorded on how they feel their day has been. (See recommendation 2) The night staff were checking on every resident at 2am and a second check was being made on those residents who were identified as needing it at 4am. These checks were being recorded. There was plenty of evidence of health needs being met. Visits from the GP, chiropodist/podiatrist, optician etc were recorded on a separate form within the file. The Salford PCT had conducted an audit of the medication storage and records. There had been a small number of discrepancies relating largely to the amount of medication being sent to Avondale by the pharmacy. The manger had sent a copy of the summary of findings to the pharmacy for them to make the necessary adjustments. The medication administration records (MAR) sheets were now being completed appropriately and three staff had attended a refresher course on medication administration. All of the residents spoken with said that they were very happy with the staff at the home and the way they were treated by them. Staff were overheard and seen interacting with residents in a respectful and cheerful manner. Avondale DS0000006694.V257237.R01.S.doc Version 5.0 Page 11 Each of the residents’ wishes in the event of their death, including their funeral arrangements, had been recorded on their care plan. Avondale DS0000006694.V257237.R01.S.doc Version 5.0 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 the following standard(s): 12, 13, 14 & 15 The resident’s physical, emotional and mental health needs will be more fully met if regular daily activities were planned. An activities co-ordinator would help this to happen. EVIDENCE: There were a small number of regular planned activities arranged. A notice of these was pinned to the door of the lounge. They included an entertainer who visits fortnightly and sings, encourages residents to dance and play musical instruments. Avondale does not currently have an activities co-ordinator. Although the post was advertised only one application was made. The manager is unable ton offer the person a post at the moment as he has come from overseas and she is awaiting him getting a national insurance number and permanent address before police and POVA checks can be made. In the relatives meeting minutes it is recorded that they too would like more activities and outings to be organised for the residents. Avondale DS0000006694.V257237.R01.S.doc Version 5.0 Page 13 The residents should be encouraged to choose where they would like to go for outings but leaflets or photographs of local attractions may have to be provided to them to help them to make a decision. A photographic directory of local resources could be produced to help with this. (See recommendation 3) Relatives and visitors are free to call at any reasonable time. This was evident during the inspection and by reading the names recorded in the visitors’ book. The residents made some choices about their daily life at Avondale. The meal times were flexible and residents were given a choice of menu A or B. Some residents chose to spend their time in the blue lounge or the quiet lounge rather than the larger, main lounge. The menu offered was varied. The cook was in the process of changing over to the winter menu. The residents have a lighter lunch with the main meal being served at teatime. There is a sweet offered at both meals during the day. The cook has obtained a silver certificate of achievement on behalf of the home. It was recorded in an earlier copy of relatives meetings that they were not happy with the lack of drinks being offered to the residents. The manager has changed this since coming into post and a mid morning and afternoon drink has been added in addition to drinks at all meal times and suppertime. There is also a small kitchen off the blue lounge so that those residents, who are able, can make themselves a drink at any time. On the first floor there is a drinks machine where carbonated drinks are available to purchase for 80p The residents have been asked in their meeting about the type of food available to them and they have had no complaints. Avondale DS0000006694.V257237.R01.S.doc Version 5.0 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 the following standard(s): 16 & 18 The systems that are in place at Avondale would reassure anyone making a complaint, that it would be investigated thoroughly. The training in adult abuse awareness would further protect the residents. EVIDENCE: There was clear evidence to show that a complaint had been thoroughly investigated and the complainant had been informed of the outcome and was happy with the result. Good recording in the residents file had enabled the complaint to be answered. The recording of the complaint, who had investigated it, how it had been investigated and the outcome, were all recorded in detail. Staff were aware of the Protection of Vulnerable Adults policy and training was provided to all members of staff, including domestic and kitchen staff, in adult abuse awareness. All visitors to the home were requested to sign the visitors’ book. Avondale DS0000006694.V257237.R01.S.doc Version 5.0 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 the following standard(s): 19, 20, 21, 22, 23, 24, 25 & 26 Avondale provides the residents with a comfortable and well-maintained living environment. The resident’s settle into the home easier with having their own possessions and photographs decorating their room. EVIDENCE: Avondale was being well maintained. The maintenance man makes regular checks on the fixtures and fittings within the home and repairs or replaces these as and when necessary. There were a number of small areas that required attention. There had been a leak in the roof, which had been repaired. However, the ceiling in one of the bedrooms was badly stained and required attention. The maintenance man was already aware of this. (See recommendation 4) Avondale DS0000006694.V257237.R01.S.doc Version 5.0 Page 16 A knob was missing from the handle on one of the bath chairs. A separate company maintains these pieces of equipment. The company must be contacted to repair the chair. (See requirement 2) The enamel on the baths was also badly marked on the top ridge by the bottom of the bath chair. One bath also had badly chipped enamel inside, revealing the cast iron underneath. This should be repaired immediately to reduce the risk of resident’s skin being damaged. (See requirement 2) The residents can access a large lounge or a smaller, quiet lounge on the ground floor. On the first floor there is a further lounge with a small area off it where residents can make themselves a drink. Residents who smoke can also use this lounge. Although the residents’ bedrooms did not benefit from ensuite facilities, there were sufficient bathrooms, a shower room and toilets within the building to meet the needs of the residents. These are equipped with rise and fall bath chairs to aid entry into the bath and grab rails are fixed next to the toilets. Commode chairs were available in resident’s rooms for use at night. There is also a passenger lift to the first floor. The residents’ own rooms were individual and had been furnished to varying degrees with ornaments, pictures, photographs and small pieces of furniture from their own home. The soft furnishings were co-ordinated in each room. A small number of the residents’ bedrooms felt cold. Although they were not using their room at this time it should be maintained at a reasonable temperature so that they can return to their room at any time during the day. (See requirement 3) Avondale provides the residents with comfortable living, which was clean and well maintained. Avondale DS0000006694.V257237.R01.S.doc Version 5.0 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29 & 30 The residents’ needs are well met by the numbers and skill mix of the staff employed at Avondale. The training provided to staff of all levels further ensures this. EVIDENCE: There are nursing staff and residential staff employed by the home to meet the different needs of the residents. Some of the staff spoken with have worked at the home for many years and have built up a good knowledge of the needs of the residents, enabling them to detect early changes in the resident’s condition. The three staff files viewed contained all of the information required to confirm their identity, experience, qualifications and viability. This would further ensure the safety of the residents. The manager had also obtained work permits, visas and national insurance numbers for any staff coming from abroad. There is an induction programme for all new staff. This covers essential training and policies to ensure that the staff can start to provide a good quality of care to the residents. Mandatory training and courses specific to the client group are also provided regularly. Certificates of training are held on the staff files. Avondale DS0000006694.V257237.R01.S.doc Version 5.0 Page 18 Staff meetings take place regularly and the minutes are held on file in the office. Additionally, the manager includes a copy of the staff meeting minutes in each envelope containing the staff pay slips. Avondale DS0000006694.V257237.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 36 & 38 The home is well run and the manager has developed new systems of recording and tracking. This makes sure that all of her responsibilities are carried out and can be easily evidenced. EVIDENCE: The manager has been in post since February 2005. Since then she has devised a number of systems of recording so that she can keep track of all of her responsibilities and make sure they are completed. For example, to make sure that the responsibility of staff accompanying a resident to hospital was not falling to the same member of staff each time, the manager devised a form for recording who had accompanied each resident on each occasion. The manager has shown a willingness to listen and learn from the residents and relatives. Avondale DS0000006694.V257237.R01.S.doc Version 5.0 Page 20 Regular meetings are held and the minutes recorded. It is clear from reading the minutes that where areas of dissatisfaction had been identified the manager had improved them to the satisfaction of all involved. The manager also sends a questionnaire to relatives, staff, residents and visiting professionals on a quarterly basis to obtain their views on how the home is being run. This makes sure that those who are unable to attend the meetings are still able to contribute their views. Staff were being supervised on a regular basis. This covered working practice, policies and procedures and identified training requests and needs. Supervision was being recorded and both parties signed the supervision record. The manager had spoken with the residents about what they should do in the event of a fire and a fire drill had been carried out successfully. Fire safety training and fire prevention equipment testing were taking place regularly. Regular checks of emergency lighting were also made. The accident book was being completed appropriately. Avondale DS0000006694.V257237.R01.S.doc Version 5.0 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 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 3 3 3 2 3 3 STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X 3 X 3 Avondale DS0000006694.V257237.R01.S.doc Version 5.0 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 OP7 Regulation 15 Requirement The daily recordings must reflect the content of the care plan and any specific requests made by the G.P., Physiotherapist or Occupational Therapist. The knob on the bath chair needs to be repaired. The enamel in the bath in bathroom F. must be repaired. The bedrooms must be constantly maintained at a reasonable temperature. Timescale for action 01/01/06 2 OP19 23 01/01/06 3 OP24 14 & 16 01/01/06 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 The ‘Getting to know you’ document should be added to until it is completed in full. Avondale DS0000006694.V257237.R01.S.doc Version 5.0 Page 23 2 3 4 OP7 OP12 OP19 The resident’s views on how their day has been should be included in the daily records. A leaflet/photographic resource directory should be produced to assist residents in making choices of outings/activities. The stained ceiling tile in bedroom 5 should be replaced. Avondale DS0000006694.V257237.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ National Enquiry Line: 0845 015 0120 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 Avondale DS0000006694.V257237.R01.S.doc Version 5.0 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!