Inspection on 11/10/07 for Avondale Lodge Care Home

This inspection was carried out on 11th October 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

Avondale Lodge Care Home 26/10/06

Avondale Lodge Care Home 31/08/05

Avondale Lodge Care Home 15/02/05

Avondale Lodge Care Home 03/02/05

Avondale Lodge Care Home 13/04/04

Avondale Lodge Care Home 05/08/03

Avondale Lodge Care Home 13/05/03

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Avondale Lodge Care Home Hythe Road Marchwood Southampton Hampshire SO40 4WT Lead Inspector Jan Everitt Unannounced Inspection 11th October 2007 09:15 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 Lodge Care Home DS0000043118.V347381.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. Avondale Lodge Care Home DS0000043118.V347381.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Avondale Lodge Care Home Address Hythe Road Marchwood Southampton Hampshire SO40 4WT 023 8066 6534 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) Mrs Wendy Osman Mr Gary John Osman Mrs Wendy Osman Care Home 14 Category(ies) of Dementia - over 65 years of age (14), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (14), Old age, not falling within any other category (14) Avondale Lodge Care Home DS0000043118.V347381.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th October 2006 Brief Description of the Service: Avondale Lodge is a registered care home providing personal support and accommodation for up to fourteen older people including those with dementia or mental disorder. The home is privately owned by Mr and Mrs Osman. Mrs Osman is currently the registered manager. A new manager is in the process of being registered with CSCI. Avondale Lodge is situated in the village of Marchwood. The detached property is one of the oldest buildings in the village, and has a small front and rear garden, with parking to the rear of the home. Service users are accommodated in 12 single rooms and 1 double room. Nine of the single rooms and the double room have en-suite facilities. Bathrooms and toilets are situated near to rooms without en-suite facilities. Service users also have access to the lounge and dining room. The registered manager said, on the 11th October 2007 that the fees ranged from £395 to £475 a week. Fee does not include hairdressing, chiropody, and other personal items. Avondale Lodge Care Home DS0000043118.V347381.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The site inspection visit to Avondale Lodge, which was unannounced, took place over a one-day period on the 11th October 2007 and was attended by one inspector. The registered manager, Mrs Osman was not in attendance but the new manager was on duty and assisted the inspector throughout. The visit to the home formed part of the process of the inspection of the service to measure the service against the key national minimum standards. The manager had returned the Annual Quality Assurance Assessment (AQAA) to the CSCI within the stated timescales and the focus of this visit to the home was to support the information stated in this document and other information received by the CSCI since the last fieldwork visit, which was an key inspection, made to the home in October 2006. Documents and records were examined and staff working practices were observed where this was possible without being intrusive. The inspector spoke to most of the residents, staff and visiting relatives in order to obtain their perceptions of the service the home provides. Those spoken to were very happy and complimentary about the care and services that are provided. Surveys had been distributed to service users, relatives, care managers, GP and other visiting professionals. One service user survey, six relative/carer surveys, six staff, three GPs and one care manager surveys were returned to the CSCI. The outcome of the surveys indicated that there was a high level of satisfaction with the service and that generally residents and relatives were pleased with the care the home provides. There were 14 residents, accommodated in the home and we were unable to communicate effectively with a small number of residents to gain their views of the service. There were no residents from an ethnic minority group. Avondale Lodge Care Home DS0000043118.V347381.R01.S.doc Version 5.2 Page 6 What the service does well: The home provides a safe, well-maintained homely environment for the service users. The service users and relatives say: ‘The garden is lovely’. ‘The home provides a happy caring environment that give relatives peace of mind’. I have been extremely impressed with the care and support my parents have received and would recommend the home to any one else. It is a safe and friendly environment and the carers do a magnificent job cheerfully and well’. ‘She could not be happier she thinks she lives in a five staff hotel, she is looked after so well’. ‘The care the staff give these elderly people is a joy to watch’. ‘I am happy with the fact that my mother is happy living there’. Assessments and care plans are detailed and inform the practices of the home to meet the needs of the service users. Staff say that they could easily care for a service user from the information recorded in care plans. Service users’ healthcare needs are provided for. Service users felt safe and secure and happy that staff could look after them properly and treated them with respect, one comment being: ‘The home care for individuals very well. They always take their preferences and choices into consideration and always respect the individuals privacy and dignity and promote independence’. Relative’s comments: ‘The home look after my mother’s special requirements and nothing is too much trouble for Lyn’. (the manager). ‘The staff are doing a very good job’. ‘The home is managed well’. The home’s routines are flexible and it promotes the right of residents to make choices for themselves and exercise personal autonomy as far as is reasonably possible. One comment on a survey from a staff member said: ‘We ensure that meeting the needs of our clients is person centred to provide choices, dignity and privacy’. A well-balanced and varied diet is offered to service users. This can be adjusted to meet their own needs and requirements. Whilst talking to service users and the surveys received from relatives and staff provided positive comments about living and working at the home. Avondale Lodge Care Home DS0000043118.V347381.R01.S.doc Version 5.2 Page 7 The home provides an appropriate and varied training programme for staff who are supported by the manager and more experienced staff. Comments received from relatives and staff support this: ‘The less experienced staff are trained and supported well by the experienced staff. I have witnessed this on several occasions. ‘The training provided by the home enable me to perform my job and meet the service users care needs’. ‘Excellent training provided’. What has improved since the last inspection? What they could do better: The medication policy and procedures must be revisited by the manager and staff to ensure that medication is stored and administered to service users by the stated procedures of the home and the practice of double dispensing must cease. The home should structure an activities programme that is tailored around the preferences, past history and social needs of all service users, taking into account their mental capacity. Avondale Lodge Care Home DS0000043118.V347381.R01.S.doc Version 5.2 Page 8 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. Avondale Lodge Care Home DS0000043118.V347381.R01.S.doc Version 5.2 Page 9 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 Lodge Care Home DS0000043118.V347381.R01.S.doc Version 5.2 Page 10 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 to this service. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are assessed prior to their admission to ensure the home can met their needs. EVIDENCE: A sample of three service user’s care plans were viewed, one being for the most recently admitted resident. The pre-admission assessment document has been reviewed and is thorough and covers all aspects of care. The resident was spoken with and she said that she had visited the home with her daughter, before admission, and the manager had undertaken the assessment at that time. The home had also received a detailed handover from her previous home. Another service user said that her daughter had organised the admission to the home and that she had been assessed before a decision was made for her to go to the home to live. The manager said there is a great deal of family involvement at the assessment time and that she receives care Avondale Lodge Care Home DS0000043118.V347381.R01.S.doc Version 5.2 Page 11 management assessments from social services if they have assessed the client before referral. This service does not offer intermediate care. Avondale Lodge Care Home DS0000043118.V347381.R01.S.doc Version 5.2 Page 12 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, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home now has systems in place to ensure the personal and healthcare needs of residents are met. The procedures for the safe management of medication are not consistently being adhered to. Service users’ privacy and dignity is upheld and promoted. EVIDENCE: A sample of three service user’s care plans was viewed. The manager has introduced a new care planning system and all care plans have been rewritten. There is a full assessment undertaken at admission and this identifies the care needs of the service users. Care plans are written to describe how to meet those needs. Risk assessments are also documented and care plans written for managing the risks. Avondale Lodge Care Home DS0000043118.V347381.R01.S.doc Version 5.2 Page 13 The inspector observed that the care plans had been signed by the service user or their representative as evidence of their involvement and agreement to the plans. Care plans had been reviewed monthly and changed if appropriate. Staff reported on the surveys that they are given full details of any changes in resident’s care or condition at the handover meeting. A survey comment from a daughter, whose parents are residents in the home stated: ‘I have read and signed the care plans for both parents. They are very supportive of my mum’s needs towards helping to care for my father and are always kind and helpful, they have exceeded expectations’. We viewed the care plan for a resident who has speech and hearing difficulties. The plan detailed how the staff had endeavoured to learn sign language for which the person’s daughter had given training to the staff to enable them to communicate with her effectively. The inspector spoke to the daughter who said ‘the home is wonderful I would not want mother anywhere else and she loves being close to where the family live’. Other comments received on surveys were: ‘The staff listen carefully to the residents and try to solve their problems’. ‘The home has a caring ethos’. ‘The carers do a magnificent job cheerfully and well’. The manager is in the process of training staff to document and record the care plans and those spoken with said that they look at the care plans and daily notes to see if there are changes and how they should care for the residents. The AQAA records that the service users have access to their GPs and other health care practitioners and are supported to attend hospital appointments. The AQAA states that the chiropodist visits 8-10 weekly and the residents can have consultation with the dentist or optician either privately, in the community, or when they visit the home annually. . The manager confirmed this, and care plans record when other visiting professionals have seen a resident. The district nurse does visit the home to treat one resident and this was recorded in his plans. The manager identified to the inspector that residents receive all their NHS entitlements. The comments on surveys from relatives indicate that they consider their relative receives appropriate medical treatment: ‘When my father was taken ill I was informed immediately as to his hospital admission’. I’ was informed immediately that mum had had a fall’. Avondale Lodge Care Home DS0000043118.V347381.R01.S.doc Version 5.2 Page 14 They keep me informed of any doctor’s visits’. Three GPs returned surveys completed and indicated they were satisfied with the overall care their patients were receiving in the home and work well with the home. The home has medication policies and procedures in place and also a copy of the guidelines for the management of medication in care homes. The home uses a monitored dosage system (MDS) supplied from Boots the chemist. The inspector observed the early morning medication round. This was being undertaken by a carer who said she had received training from the dispensing pharmacist. The inspector observed that medication had been dispensed from the blister packs into individual screw lid pots, and labelled with the resident’s name, prior to the round. These were then dispensed to each service user in bulk from this pot. We identified this practice as unsafe and that staff are not following safe procedures for the administration of medications as described in the home’s own procedures. The practice of double dispensing was discussed with the manager and attention was drawn to the policy, which states this should not take place. The manager agreed to cease this practice immediately, to place the policy and procedures in the medication charts folder, train the staff and reiterate safe procedures for the administration of medication. The manager said that she will endeavour to purchase a drugs trolley for the purpose of storing the blister packs and medication can be dispensed straight from the trolley at medication times. One service user was choosing to self-medicate her morning medicines and a risk assessment was recorded in the care plans. All rooms had lockable storage for the purpose of keeping medication if residents choose to manage their own medicines. Medication was being stored appropriately, although the home has no specific fridge for this purpose. The AQAA stated that the home ensures that service users are treated with respect and their privacy respected. One service user said that the carers were ‘very kind and caring’. A relative survey comment said that staff were ‘caring and treated the service users with respect’. Another said: ‘The staff value the residents and try to increase their self-esteem’. We observed that residents were friendly with one another and chatted throughout the day. The staff were observed to interacted well with residents and were overheard speaking to them in a respectful manner. The inspector Avondale Lodge Care Home DS0000043118.V347381.R01.S.doc Version 5.2 Page 15 asked one of the carers about some of the residents and she was conversant with their needs and preferences. Avondale Lodge Care Home DS0000043118.V347381.R01.S.doc Version 5.2 Page 16 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, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are able to exercise choice over their lives, participate in social activities, receive visitors as they wish and enjoy a choice of meals taken in a relaxed atmosphere. EVIDENCE: The home has no specific activities programme. The manager is striving to increase the activities to include a more structured and planned programme. The home has various outside entertainers that visit the home and there is an entertainment folder that records the activities undertaken in the home. A person visits the home once a week who demonstrates crafts and practices some armchair exercises with them. The manager told the inspector that at present the service users decide on what they would like to do on a day-to-day basis. Generally the comments received from relatives were positive about the home’s activities and how the residents spend their days. One relative commented: Avondale Lodge Care Home DS0000043118.V347381.R01.S.doc Version 5.2 Page 17 ‘It would be beneficial if they could have more outings, do more activities with those who can and have outside organisations visit occasionally i.e. musicians. ‘Maybe more stimulation or activities although I understand money may be an issue. Discussion with the manager indicated that the activities programme in the home is under discussion. The AQAA stated that over the next twelve months the manager wants to introduce a programme of activities after consultation with the service users as to their wishes, taking into account their social histories and past lives. The manager also told the inspector that two staff members are going to attend an activities training course that will support the home when identifying appropriate activities for those with dementia. A relative spoken with at this visit said that she comes in several times a week, as so do the rest of the family, and that her mum goes out every week-end to stay with them. She also told the inspector that she plays cards with a group of residents several times a week and they now look forward to this. The inspector observed a group of resident’s playing cards on the afternoon of this visit. A resident who has hearing and communication difficulties is taken by the manager to her club once a week to meet old friends and although the club is a considerable distance from the home, the manager makes it her responsibility each week to fulfil this resident’s wishes. Service users told the inspector that they really enjoy sitting in the garden, which has a very pleasant sitting area. One service user commenting: ‘I am out there at the least hint of sunshine, I love being outdoors in the garden’. The manager said that she encourages the service users to help in the garden and one service user in particular enjoys this. The visitor’s book gave evidence that the home has a number of visitors each day and that there is a high level of family involvement with the home. This was reflected by the comments returned on the 7 surveys that relatives returned to the CSCI: My parents are Christians and the local church group come on a Sunday to share communion. The home does encourage visitors at all times and are happy to support me in taking my mum out regularly on excursions. There is also a resident who is deaf and dumb and uses sing language and the staff have made great efforts to learn to sign.’ ‘Each Sunday she is always ready and waiting to be picked up for church’. ‘The staffs’ loving care and persuasion help her to exercise and walk in the gardens’. ‘Nothing is too much trouble for them’. ‘They make visitors feel very welcome’. The staff encourages residents to go out with family and friends’. Avondale Lodge Care Home DS0000043118.V347381.R01.S.doc Version 5.2 Page 18 The service users have choices of when they get up in the morning and go to bed at night. The inspector observed that one resident was choosing to stay in bed most of the morning and the manager said this was her usual routine; she liked being on her own on her bed. She confirmed to the inspector that this was her choice. When asked about choices of getting up one service user said ‘No we do not get choices’. The inspector challenged this with the manager who said that most definitely service users have choice of how they wish to undertake the activities of daily living and spend their days. This was supported by other service users spoken to, who said they could do as the wished and some said they liked to get up early. The inspector observed throughout the visit that service users where coming and going at their will and able to do as they wished. The service user’s rooms were pleasant and many of them have been individualised by the service user with their own belongings. The couple that live in the home have chosen to have one room as their bedroom and the other as a lounge. Comments from relatives indicate that they consider the home to be good and that ‘The home encourages them to be as independent as possible’. ‘In all aspects of care and attention she could not be as well looked after at home’. The home has employed a cook/housekeeper since the last inspection. The inspector visited the kitchen, which was clean and well organised, and spoke to the cook. She showed the inspector the planned menus but said that she knows the residents’ likes and dislikes and tailors the menus around these. Although not on the menu, alternative meals are available and records are kept of what residents eat. We observed three people were having a vegetarian menu. We spoke to service users who said they enjoyed their lunch, which was well presented and looked nutritious in content, with the exception of one service user who said she was unable to chew it owing to a sore mouth. She was immediately offered alternative food. The cook was also preparing a fortified soup for one lady who wishes to have soup every day. This is done under the guidance of dieticians and supplements are prescribed. Food handling hygiene course certificates for staff are displayed on the kitchen wall. The manager said staff are to attend a menu planning and nutrition training within the next month, to build on their knowledge on assessing nutritional needs in the elderly. Avondale Lodge Care Home DS0000043118.V347381.R01.S.doc Version 5.2 Page 19 Relative’s comments on survey were generally positive one saying: ‘Her meals are tailored made to suit her as she is very hard to please’. ‘Always very attentive to all their needs’. The AQAA states that the home now undertakes nutritional assessments and all service users are regularly weighed, the inspector observed nutritional risk assessments and weight charts in the care plans. Avondale Lodge Care Home DS0000043118.V347381.R01.S.doc Version 5.2 Page 20 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. This judgement has been made using available evidence including a visit to this service. Service users feel that complaints will be taken seriously and acted upon and they are protected by policies and procedures of the home and staff awareness for the prevention of abuse. EVIDENCE: The complaints police is stated in the Statement of Purpose. The home has received one verbal complaint that was recorded and dealt with and resolved quickly and all parties were satisfied with the outcome. The manager told the inspector that she reviews the policies regularly and discusses these with staff. Staff surveys received indicated that staff are aware of what to do when a concern is raised. One commenting: ‘Most information and communication is done by the manager but if need be that staff will speak to relatives’. Comments on surveys received from relatives: ‘The manager is always on hand if there is a problem or if we need to speak to her’. ‘The manager has listened carefully and acted appropriately’. ‘The manager is always willing to discuss concerns’. ‘I have never had reason to question the care of my relative’. Avondale Lodge Care Home DS0000043118.V347381.R01.S.doc Version 5.2 Page 21 ‘The owner and the manager are both very approachable’. ‘If I was unhappy with the care I would make it my business to discuss this with the home’. A care manager’s comment on the survey indicated that there had been a concern recently with her client and this has been dealt with appropriately. Residents spoken with said they would speak to the manager if they had concerns. The AQAA states that the manager has reviewed some policies on abuse and neglect to ensure staff are up to date on adult protection. The adult protection local policies were discussed with the manager and she is aware of the procedure should there be any allegations or incidences of abuse. All staff are trained to NVQ level 2 and therefore have knowledge in complaints and protection. Staff surveys returned indicated that they would know what to do if they suspected or witnessed abuse. Avondale Lodge Care Home DS0000043118.V347381.R01.S.doc Version 5.2 Page 22 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. This judgement has been made using available evidence including a visit to this service. The home provides a clean, safe and homely environment for those who live and visit there. EVIDENCE: On the day of this visit the home was clean, bright and homely. The physical appearance of the home demonstrates that care in taken in the upkeep of the environment. A maintenance book has been introduced to ensure that all dayto-day snags are dealt with. When visiting the rooms the inspector observed they were pleasantly decorated and had been made individual by personal belongings. Avondale Lodge Care Home DS0000043118.V347381.R01.S.doc Version 5.2 Page 23 The manager says the home has a decorating schedule in place and rooms are decorated and new carpets laid before a new resident is admitted. The most recent resident was spoken to by the inspector and she confirmed she had visited the home when her room was nearly finished and that the home had allowed her to bring how own chair and bed. She reported that she is extremely happy with her room as it is not too large and she looks out onto the road and is able to ‘watch the world go by’. Comments from relatives indicate a high level of satisfaction with the environment: ‘It is very much home from home small, friendly, homely and caring’. ‘I am happy with everything at Avondale Lodge and it has been completely refurbished ‘. ‘The home has a very homely feeling’. Service users spoken with at the time of this visit said they were happy with their home. The garden and large patio area are very well maintained and the lounge area looks out onto the garden, for service users to enjoy. Many of the service users told the inspector that they enjoyed sitting in the garden in the finer weather. The home has an infection control policy and procedures in place. Staff files evidence that training has been provided for infection control. Hand washing facilities with disposable towels are available and sanitising gel is also available in all areas of the home. Protective clothing and disposable gloves are available for staff. The cook is also the morning cleaner and the inspector discussed with her and the manager the process for her to decontaminate/change her outer clothing before going into the kitchen to cook. She said she does do this and is supplied with an overall and apron. The AQAA states that the general hygiene of the home has improved over the last twelve months with the employment of a cleaner and the introduction of a cleaning schedule that the manager audits. Staff comments confirm that training is supplied and that they are aware of infection control principles Avondale Lodge Care Home DS0000043118.V347381.R01.S.doc Version 5.2 Page 24 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, 28,29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The numbers and skill mix of staff meets Service users needs. Service users are protected by the robust recruitment practices of the home. Staff receive the training to do their jobs to ensure service users are in safe hands at all times. EVIDENCE: The staff rotas demonstrated that two carers are on duty all day, a cleaner/cook and the manager are also on duty during the day for approximately six days per week. There is one awake staff and one sleep-in staff on duty each night. Observation of practices at the time of the visit would indicate that sufficient staff were on duty to meet the needs of the 14 service users in residence. Comments on relatives and staff survey cards indicate that there is generally sufficient staff on duty to meet the needs of the service users: ‘The service does well in meeting individual needs’ ‘I am impressed with the level of care and support my parents receive’. ‘Very attentive to all her needs’. Avondale Lodge Care Home DS0000043118.V347381.R01.S.doc Version 5.2 Page 25 ‘The staff care for individuals very well’. A comment on a staff survey said: ‘There are times when some residents need two carers and the other residents are left waiting because the two carers are helping one resident’. Conversely other staff comments were: ‘The manager is good because she is so free and helps a lot’. The manager is always on hand to help’. The staff group is from a mixed cultural background. The home provides a good training programme for staff. All members of care staff have achieved NVQ level 2 standard. The newest recruit told the inspector that she is commencing her NVQ level 2 in January 08. The AQAA states that the home is striving to improve on staff training and development programme for the NVQ level 3 carers. Staff surveys comment that the training is available and that they are encouraged to undertake the training on offer and that has been identified as them needing through appraisal and supervision sessions, which now take place regularly and records of these were evidenced in the staff files. Staff spoken with at the home said that they were encouraged and supported by the registered manager to attend training courses and obtain qualifications Each member of staff has a training file which records all training undertaken by them and this includes the mandatory health and safety annual updates. The inspector viewed the files of the staff tracked, and they demonstrated up to date training. The manager told the inspector that she is in the process of trying to procure dementia training for all her staff. Comments from the staff surveys say: ‘Good training I learn a lot from my trainings’. ‘I have enough knowledge and experience to do this type of job’. ‘The training and the refreshment courses provided by the home manager gives me the ability to perform my job to meet individual needs and enables me to learn new ideas’. ‘The home provides training for their staff and a lot more’. The AQAA states that the induction programme is in line with Skills for Care induction standards. The AQQA states that the home’s programme has improved on last year and now includes all the home policies on abuse, neglect, infection control and staff members sign to say they have read the documentation on COSHH guidance. Comments from staff and evidence in the staff training files demonstrated that an induction programme is in place. A comment on a staff survey said: Avondale Lodge Care Home DS0000043118.V347381.R01.S.doc Version 5.2 Page 26 ‘The induction was good and clear’. Other surveys returned indicated that staff had undergone an induction period and that information was readily available to them to support the care practices. We viewed a sample of three staff personnel files. The recruitment process is robust and all information identified on Schedule 2 of the Care Home Regulations was present in each of the files. The comments on staff surveys indicate that the home carried out checks and obtained references on them before they could commence working at the home. ‘I had to start working after my CRB and references were checked and done’. ‘The home manager always gets documents from the staff before commencing the job which is essential for the safety of the residents and for legal reasons’. Avondale Lodge Care Home DS0000043118.V347381.R01.S.doc Version 5.2 Page 27 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is managed in the best interests of the service users and the safe working practices operated in the home protects them. Service users’ financial interests are safeguarded. EVIDENCE: The AQAA states that a new manager is in post and she will co-ordinate all pre-admission assessments and oversees the day-to-day management of the home. She is in the process of undertaking her Registered Managers Award (RMA). The manager also has experience with care management. The manager is in the process of registration with the CSCI. She has been in post Avondale Lodge Care Home DS0000043118.V347381.R01.S.doc Version 5.2 Page 28 for some months now and demonstrated to the inspector the new systems she has introduced to improve care planning/risk assessments and domestic systems to maintain the hygiene standards of the home. The comments from the relative surveys, speaking to visiting relatives, service users and staff members said complimentary comments about the manager: ‘The owner and manager are very approachable’ ‘The manager is always on hand and if there is a problem or we just need to talk to her’. ‘The home is friendly and the manager is very approachable’. ‘The home is managed well.’ ‘The manager is good because she is so free and helps a lot’. ‘We are well informed by the manager of any changes in residents’ care’. We observed the manager interacting well with service users and relatives and she dealt with a very anxious lady in a sensitive manner by reiterating and reassuring her of her husband’s medical condition. The manager has carried out a satisfaction survey for service users and relatives and has made improvements from the result of this survey. The inspector viewed the results of the surveys returns. Quality assurance systems are in place and the manager audits a sample of care plans monthly to ensure they are reviewed appropriately, medication charts to ensure they are completed, cleanliness of the home and records of service user’s monies. The manager told the inspector most of the communication between staff is verbal and informal discussions do take place to discuss changes in the procedures in the home. She identified that currently there are no formal staff meetings taking place. She plans that staff meetings will commence on a quarterly basis with an assurance from staff they will attend them twice yearly. The manager does make unannounced visits to the home during the late evenings to ensure the night staff have supervision. The home does hold small amounts of personal monies for service users. All monies are stored in separate containers. The monies are held in a secure environment and records and receipts are kept of all transactions. Records seen for a sample of two service users matched the amount that was held. The AQAA states and the manager told the inspector that she now audits these records and monies monthly. The inspector saw the manager’s signature on the records as evidence that this does take place. The training records demonstrated that staff have undertaken health and safety mandatory training in moving and handling, fire, infection control. All staff have now received first aid training and training in COSHH guidance. This training is fully funded by the home and staff are expected to attend these sessions. Avondale Lodge Care Home DS0000043118.V347381.R01.S.doc Version 5.2 Page 29 We viewed a sample of servicing certificates for systems and equipment. These evidenced current servicing certificates for fire alarm system, PAT for small electrical appliances, passenger lift and the bath and general hoists. The accident book was viewed and this was recorded appropriately. The fire log demonstrated that the fire alarm system is tested weekly and emergency lighting monthly. Evidence of staff training was also recorded in this log. The home has a fire risk assessment in place. Comments from relatives and service users indicate that they consider the home to be: ‘a safe friendly environment’. ‘The home provides a healthy and safe environment for service users to make them feel at home’. Avondale Lodge Care Home DS0000043118.V347381.R01.S.doc Version 5.2 Page 30 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 X 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 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 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 3 Avondale Lodge Care Home DS0000043118.V347381.R01.S.doc Version 5.2 Page 31 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 Reg 13(2) Requirement The registered person must ensure that the administration of medication is undertaken as stated in the polices and procedures of the home. Medication must be administered directly to service users from the containers/packets in which they were dispensed. Timescale for action 16/11/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Avondale Lodge Care Home DS0000043118.V347381.R01.S.doc Version 5.2 Page 32 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 Avondale Lodge Care Home DS0000043118.V347381.R01.S.doc Version 5.2 Page 33 - 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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