CARE HOME ADULTS 18-65
Avondale Lodge Care Home 419 Central Drive Blackpool Lancashire FY1 6LE Lead Inspector
Wesley Cornwell Unannounced 3 May 2005 14:45 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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 Lodge Care Home F57 F09 S64034 Avondale V219371 030505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Avondale Lodge Care Home Address 419 Central Drive Blackpool FY1 6LE 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) 01253 341118 Pro-Care Dispersed Housing CRH Care Home 6 Category(ies) of MD Mental Disorder 6 registration, with number of places Avondale Lodge Care Home F57 F09 S64034 Avondale V219371 030505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: The service should employ a suitably and experienced manager who is registered with the Commission for Social Care Inspection. The home is registereed for a maximum of 6 service users with a mental disorder excluding leanring disability of dementia (MD). Date of last inspection 25 October 2004 Brief Description of the Service: Avondale Lodge is a care home registered for 6 young adults with mental health problems aged 18 to 65 years. The home is situated in the central area of Blackpool close to the town centre. The accommodation provides 6 single rooms which are located on the first and second floor. Toilet and bathing facilities are also located on the first floor. There is no lift available at this home. Avondale Lodge Care Home F57 F09 S64034 Avondale V219371 030505 Stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced and started at 2.45m and took place over 2.5 hours. The Inspector spoke to one staff member, two residents and the manager. One resident completed a comment card providing their views about the home. Staff and care records were also examined. A full tour of the premises was undertaken with the staff member. What the service does well: What has improved since the last inspection?
The home has improved its procedures for the recruitment of staff to ensure the protection of residents. The staff work well together and have a good understanding of their role within the home. Staff training is more organised and structured. For example, staff members now have an individual training and development assessment, which had identified training needs and these were being met. The homes procedures for the administration of resident’s medication have been reviewed to ensure these are stored and administered safely. The manager of the home has applied to be registered with the Commission.
Avondale Lodge Care Home F57 F09 S64034 Avondale V219371 030505 Stage 4.doc Version 1.30 Page 6 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 Lodge Care Home F57 F09 S64034 Avondale V219371 030505 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Avondale Lodge Care Home F57 F09 S64034 Avondale V219371 030505 Stage 4.doc Version 1.30 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 and 4 The admission and assessment procedures were clear to ensure the care needs of residents are met. EVIDENCE: The records of residents admitted to the home had full assessment information. Staff members confirmed they had access to this information and could describe in detail the care needs of residents. One resident spoken to said they had undertaken an introductory visit to the home before admission to view the premises, meet the staff and discuss their health and social care needs. One resident spoken to confirmed they were happy their needs were being met by the home. Avondale Lodge Care Home F57 F09 S64034 Avondale V219371 030505 Stage 4.doc Version 1.30 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7 and 8 Promotion of residents health, personal and social care is taken seriously and closely monitored to ensure they are met. EVIDENCE: Individual records are kept for each resident with a plan of care setting out in detail the action that needed to be taken by care staff to ensure all aspects of health, personal and social care needs of the residents were met. Significant events had been recorded and daily entries made setting out the care given. Entries made on care plans showed good communication between the home and health and social care professionals. Discussion with residents confirmed they are encouraged and supported by staff to live an independent lifestyle and make their own decisions about their lives. One resident spoken to said they were consulted by the manager and staff members about the day to day running of the home. Regular meetings are held at the home to consult residents about upcoming events to enable them to have their say about the service provided by the home.
Avondale Lodge Care Home F57 F09 S64034 Avondale V219371 030505 Stage 4.doc Version 1.30 Page 10 One resident spoken to all said they were happy living at the home and were satisfied with their level of involvement in decision making within the home. Avondale Lodge Care Home F57 F09 S64034 Avondale V219371 030505 Stage 4.doc Version 1.30 Page 11 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13 and 17 Education and employment opportunities are promoted to ensure residents have opportunities for personal development. Meals are well managed and provide daily variation for people living in the home. EVIDENCE: There are no residents at this home who are pursing education or employment opportunities. Discussion with residents confirmed this was through choice and they were aware that staff support was available if required. Entries made on care plans confirmed staff had discussed with residents participating in activities of their choice. Residents spoken to said they were encouraged by staff to exercise choice over their lifestyle and preferred routine. One resident said, “I am happy living at the home. Its good to know the staff are there to provide support if I need it. I had a problem recently with my benefits and the staff were really helpful.” One resident spoken to said the manager consults them each week about the homes menu. Food is purchased for the week and then residents can choose
Avondale Lodge Care Home F57 F09 S64034 Avondale V219371 030505 Stage 4.doc Version 1.30 Page 12 daily what they would like to eat. Residents were observed by the Inspector having open access to the kitchen to prepare snacks and drinks. Avondale Lodge Care Home F57 F09 S64034 Avondale V219371 030505 Stage 4.doc Version 1.30 Page 13 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 and 20 Promotion of health is taken seriously. Residents welfare is closely monitored and health needs were met. EVIDENCE: Individual records are kept for each resident with a plan of care setting out in detail the action that needed to be taken by care staff to ensure all aspects of health, personal and social care needs of the residents were met. Significant events had been recorded and daily entries made setting out the care given. One resident who suffers from anxiety had been taught relaxation techniques such as breathing exercises. The staff member on duty had a good understanding of the needs of the resident and was able to describe how they would recognise the resident required assistance and how this would be provided. The resident told the Inspector “The staff are very helpful and I value their support”. Residents accommodated at the home were having their medication administered by the staff. These were stored in suitable secure facility. Medication records checked were found to be up to date and well maintained. Avondale Lodge Care Home F57 F09 S64034 Avondale V219371 030505 Stage 4.doc Version 1.30 Page 14 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 Arrangements for complaints are handled well and there is a procedure for responding to allegations of abuse. This ensures a proper response and safety for people, ensuring they are listened to. EVIDENCE: The home has a detailed complaints procedure, which is made available to all residents on admission to the home. Residents spoken to were aware of how to make a complaint and felt these would be listened to and acted upon. The home has a procedure in place for dealing with allegations of abuse. The manager and staff spoken to had a good understanding of the procedures to be followed in the event of any allegations or suspicion of abuse or neglect. Avondale Lodge Care Home F57 F09 S64034 Avondale V219371 030505 Stage 4.doc Version 1.30 Page 15 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,26 and 30 The lack of a planned maintenance and renewal programme for the redecoration and refurbishment of the home does not ensure residents live in a comfortable, homely and safe environment. EVIDENCE: There has been no real progress in upgrading the environmental standards in the home since the last inspection. A recommendation made during the last inspection was for the homes owner to provide two double sockets in residents bedrooms. There has been no progress in this area. The walls in one bedroom had been painted. However, the woodwork had not been painted. Resident bedrooms are all in need of refurbishment. The environment throughout the building is in need of upgrading. The manager of the home was reminded a risk assessment of the building should be kept under review and made available to the Commission. It was observed during the visit the home was clean and hygienic. Avondale Lodge Care Home F57 F09 S64034 Avondale V219371 030505 Stage 4.doc Version 1.30 Page 16 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32,43,35 and 36 The policies and procedures for the recruitment of staff are robust and provide safeguards for the protection of residents. Staff are well trained to ensure they have the competencies to meet residents needs. The deployment of staff throughout the day is sufficient to meet the needs of residents. EVIDENCE: The home has a small staff team and turnover is low. Recruitment procedures are thorough to ensure the safety of residents. Records showed that training is being provided by the home. Staff members had an individual training and development assessment, which had identified training needs and these were being met. Staffing levels were sufficient for the number of residents living at the home. Residents spoken to were very positive in their comments about staff members and were happy with staffing levels. Staff at the home were able demonstrate a good understanding of residents needs. They are well supported and supervised by the manager. One member of staff confirmed they receive formal supervision with the manager.
Avondale Lodge Care Home F57 F09 S64034 Avondale V219371 030505 Stage 4.doc Version 1.30 Page 17 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,39 and 42 The home is well managed and run in the best interests of residents EVIDENCE: There has been no registered manager at this home for over 12 months. The present manager has applied to be registered with the Commission and her application is being dealt with. Residents and staff members were very positive in their comments about the homes manager and her style of management. Residents spoken to said they found the manager to be approachable, supportive and helpful. Staff members said they found the manager was supportive and provided a clear sense leadership. The manager has developed good systems to gather staff, residents and relative’s views as part of her monitoring of quality. Staff spoken to had a clear understanding of their role and what is expected of them during their shift.
Avondale Lodge Care Home F57 F09 S64034 Avondale V219371 030505 Stage 4.doc Version 1.30 Page 18 Observation of care plans and discussion with staff confirmed the home has effective communication procedures in place to ensure the health care needs of residents are met. Inspection of maintenance records identified that the homes owners were not maintaining electrical equipment within the home. This places vulnerable people at risk. An immediate requirement notice was issued to the home requesting immediate action is taken to ensure the safety of all persons living at the home. Avondale Lodge Care Home F57 F09 S64034 Avondale V219371 030505 Stage 4.doc Version 1.30 Page 19 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x 3 x Standard No 22 23
ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score 3 3 3 x x
Score Standard No 24 25 26 27 28 29 30
STAFFING Score 2 x 2 x x x 3 Standard No 11 12 13 14 15 16 17 3 3 x x x x 3 Standard No 31 32 33 34 35 36 Score x 3 x x 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Avondale Lodge Care Home Score x 3 3 x Standard No 37 38 39 40 41 42 43 Score 2 x 3 x x 1 x F57 F09 S64034 Avondale V219371 030505 Stage 4.doc Version 1.30 Page 20 Yes 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 37 Regulation 8 Requirement Timescale for action 25/5/2005 2. 42 23 The registered person must ensure that the home has a registered manager at all times. (Previous timescale of 31/1/2005 not met) The registered person must 25/4/2005 ensure equipment at the home is maintained and in good working order. 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. 2. 3. Refer to Standard 24 26 42 Good Practice Recommendations The registered person should produce a programme for the routine maintenance of the fabric and decoration of the home. At least 2 double sockets should be provided residents accommodation. The registered proprietor should ensure the risk assessment of the building undertaken in relation to radiator guards and pre-set water valves to sinks in service users accommodation is reviewed and updated on an ongoing basis and a copy the assessment is supplied to the Commission with the date of review.
F57 F09 S64034 Avondale V219371 030505 Stage 4.doc Version 1.30 Page 21 Avondale Lodge Care Home Commission for Social Care Inspection Area Office, Unit 1 Tustin Court Port Way Preston PR2 2YQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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