CARE HOMES FOR OLDER PEOPLE
Avondale Lodge Care Home Hythe Road Marchwood Southampton Hampshire SO40 4WT Lead Inspector
Marilyn Lewis Unannounced Inspection 26th October 2006 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 Lodge Care Home DS0000043118.V311841.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.V311841.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.V311841.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 31st August 2005 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 and run by Mr and Mrs Osman. Mrs Osman is also the registered manager. 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 30th October 2006 that the fees ranged from £375 to £450 a week. Avondale Lodge Care Home DS0000043118.V311841.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place over two days, the 26th and 30th of October. The registered manager was on leave at the time of the first visit and carers on duty were unable to access some records required to complete the inspection. On the first visit the inspector toured the home and met with five service users, a relative and two carers. Care plans were sampled for seven service users and records seen for medication. During the second visit the inspector met with the registered manager and saw records including those for staff training, staff recruitment, accidents, and complaints. Care plans were seen for the thirteen service users currently in residence. What the service does well:
Service users spoken with were satisfied with the care they received at the home. One service user said ‘ it’s my home and I like it here’. A relative commented that she ‘had no complaints whatsoever’ with the care provided. Service users and their relatives are able to visit the home before making a decision about taking a place there and are provided with a written contract on admission. Service users are protected by the home’s procedures for dealing with medicines. Only staff who have received training in the administration of medicines are able to give medication. Staff were seen to knock on doors and wait before entering rooms and spoke with service users in a friendly, respectful manner. Service users said that they felt their right to dignity and privacy was upheld. One service user said that the carers always treated her with respect. Service users said that they enjoyed the choice of food provided at the home and there was a relaxed atmosphere in the dining room during lunch. The registered manager said that no complaints had been received by the home. A service user said that if she had any concerns she would talk with the registered manager whom she felt would ‘listen and sort it out’. Staff had received training in the protection of vulnerable adults and were aware of the procedures to follow should abuse be suspected. Avondale Lodge Care Home DS0000043118.V311841.R01.S.doc Version 5.2 Page 6 Avondale provides a clean, safe and homely environment for all who live and work there. Service users said that they liked their rooms and that they ‘had all they need’. Staff said that the registered manager is very supportive and encourages them to obtain qualifications. Seven of the nine care staff employed hold National Vocational Qualification (NVQ)level 2 or above in care. Service users, visitors and staff benefit from the registered manager’s open approach to management. It was evident during the second visit that Mrs Osman had a good rapport with service users, visitors and staff. Service users said that Mrs Osman was approachable and easy to talk with. What has improved since the last inspection? What they could do better:
The registered manager was aware that service users care plans required reviewing and had started the process, with seven of the thirteen care plans reviewed and rewritten. Some of the care plans seen did not provide all the information required including nutritional assessments. The documents did not show evidence of involvement by service users or if appropriate their relatives
Avondale Lodge Care Home DS0000043118.V311841.R01.S.doc Version 5.2 Page 7 in the reviewing of the plans. The care plans did not contain risk assessments for daily living and social activities. Care staff who have received training in food hygiene, prepare the meals for service users. On the first visit to the home, two carers were on duty. While one carer cooked the lunch meals only one carer was available to provide care for the thirteen service users resident at the home, two of who were in their bedrooms. When a service user required assistance to visit the bathroom this left service users in the lounge without a carer, although the carer preparing meals was close by in the kitchen and able to see into the dining room and some of the lounge. Care staff had not received regular formal supervision. The registered manager said that she was arranging for supervision meetings to be held and was also considering arranging for an experienced carer to attend training in supervision skills so that she would be able to undertake supervision for some staff members. Staff records were seen for three staff members. Two of the records contained the documentation required but the third file held only limited information and it was not possible to confirm that written references, proof of identity or Criminal Records Bureau (CRB) and Protection of Vulnerable Adult (POVA) checks had been completed. The registered manager said that the information was held at another home, which was the umbrella home for CRB checks. Small amounts of service user’s personal monies are held at the home. The monies are stored securely and receipts are kept for all transactions. However records seen did not match the amounts of money held, although in most cases the amount held was larger than the amount recorded. The registered manager said that she would investigate the discrepancies. 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 DS0000043118.V311841.R01.S.doc Version 5.2 Page 8 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.V311841.R01.S.doc Version 5.2 Page 9 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): 2, 3, 5 and 6 Quality in this outcome area is good. The judgement has been made using available evidence including visits to the service. Care needs assessments are undertaken for prospective residents to ensure the home can meet their care needs. Service users are able to visit the home before making a decision about living there and are provided with a written contract on admission. The home does not provide intermediate care. EVIDENCE: The registered manager said that the home’s Statement of Purpose and Service User Guide were currently being reviewed to provide service users and their relatives with up to date information following the building of the extension to the property and the increase in the number of service users. Full care needs assessments were seen for three service users. The assessments had been undertaken by the registered manager at the homes of the service users prior to their admission. The assessments covered all aspects
Avondale Lodge Care Home DS0000043118.V311841.R01.S.doc Version 5.2 Page 10 of care needs. A care needs assessment had not been fully completed for one service user who had recently moved into the home. The registered manager said that the service user had visited the home frequently before a place at the home was offered and staff were aware of her needs. Care plans were in place. The service user’s relative spoken with when visiting said that she had no concerns about the care provided and that staff had demonstrated that they understood her relative’s needs. On admission each service user is provided with a written contract giving the home’s terms and conditions for residency. The contract states what services are included in the fees and services such as hairdressing that are available at an additional cost. A service user said that she had visited the home to meet staff, other service users and see her room before making a decision to live there. A visitor also said that she had brought her relative to see the home and meet people before she decided to take a place there. The home does not provide intermediate care. Avondale Lodge Care Home DS0000043118.V311841.R01.S.doc Version 5.2 Page 11 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 and 10 Quality in this outcome area is adequate. The judgment has been made using available evidence including visits to the service. Service users health care needs are met and they are protected by the home’s procedures for dealing with medicines. The registered manager is addressing the need to provide up to date care plans and risk assessments for all service users to ensure their care needs are met. EVIDENCE: On the first visit care plans were seen for seven service users and the other six were seen on the second visit. The registered manager said that she was in the process of reviewing and rewriting all the care plans and had completed seven. The rewritten care plans seen contained information on the care needs of the service users and the support required to meet those care needs. The care plans seen showed evidence of regular monthly review until July 2006 but not since October when the registered manager started to rewrite the documents. The documents did not contain assessments for nutrition and there was no record of service user’s weight being monitored even though some plans said that the person should be weighed monthly. Record charts for weights were in
Avondale Lodge Care Home DS0000043118.V311841.R01.S.doc Version 5.2 Page 12 the files but had not been completed. Photographs were not available for all service users including one whose care plan said that there was a risk of them wandering. This puts them at risk if they do wander from the home and people who do not know them, such as the police, would not have a photograph for assistance when looking for them. A visitor spoken with said that she knew about the care plans that were in place for her relative. However care plans for other service users did not indicate that the service user or if appropriate their relatives had been involved in the reviewing of the plans. A service user said that she did not know about a care plan but that staff cared for her well and ‘did all I could wish for’. A care staff member did not know what was written in the plans but was able to say what the care needs of a resident were and the support required to meet those needs. Care planning was discussed with the registered manager who was aware of the issues being raised and had begun to address them by rewriting and reviewing the documents. Mrs Osman also said that she was looking to start a key worker system where by care staff would be linked to a number of service users and would be involved in their care planning and reviews. Staff spoken with said that they were not currently involved in reviewing care plans. Although the registered manager had noted that risk assessments were required for the service users, no risk assessments were included in the plans. Mrs Osman said that she was risk assessing service users for their daily living and social activities whilst reviewing their care plans. Records seen indicated that service users were able to access the services of their GP and other health professionals including the district nurse and psychiatrist as necessary. Daily records for one service user noted that she had attended her GP practice with the support of a relative. The registered manager said that the dentist and optician visited annually and on request and the chiropodist attended every eight weeks. On the first visit to the home the procedures for dealing with medicines were discussed with the carer in charge. Medication records seen had been completed appropriately. The majority of the medicines were supplied in blister packs. At the time of the visits no one was receiving a medicine that required storage in the controlled medicine cupboard and no one was administering their own medication. The carer said that only staff who have received training in the administration of medicines are allowed to give medicines to service users. During the visits to the home staff were observed knocking on doors before entering rooms and they spoke to service users in a friendly, respectful manner. One service user said that the carers were ‘very kind and caring’.
Avondale Lodge Care Home DS0000043118.V311841.R01.S.doc Version 5.2 Page 13 A relative also said that staff were caring and treated the service users with respect. Avondale Lodge Care Home DS0000043118.V311841.R01.S.doc Version 5.2 Page 14 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 and 15 Quality in this outcome area is good. The judgement has been made using available evidence including visits to the 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: During the visit service users were seen to choose whether to join others in the lounge or stay in their own rooms. One service user sitting in the lounge was busy knitting and another was looking at a magazine. During the morning a visitor spent time playing card games with her relative and other service users who wished to participate. The registered manager said that there was not a formal programme of activities in place as service users preferred to decide on a daily basis what they would like to do. One service user said that they liked to sit and chat, while another said that she preferred to sit quietly. Two service users said that they enjoyed having their hair done by the hairdresser who visits weekly. A carer said that time was usually spent in the afternoons with service users, on a one to one basis, for chats or walks around the garden.
Avondale Lodge Care Home DS0000043118.V311841.R01.S.doc Version 5.2 Page 15 Records seen indicated that some service users frequently went out into the community with relatives and one attended a club for the deaf. The registered manager said that occasional outings were organised to areas of local interest with a recent one to Lymington town and harbour. A minister from a local church visits the home weekly to take services for those who wish to attend. A service user said that she was able to have visits from her relatives as she wished and a relative visiting said that she always felt welcome at the home. Menus seen indicated that service users were offered a varied diet. Choice was not documented on the menus but service users were asked on a daily basis whether they would like the main meal or prefer a different option. On both visits some service users had chosen a different main meal. One lunch was chicken pie, mashed potato and mixed vegetables followed by fruit and cream. Some service users chose to have vegetarian burgers. All service users appeared to enjoy their meal and one said that the food was ‘always very good’. The atmosphere in the dining room was homely and relaxed during lunch. The home was not recording which meals service users had eaten and the registered manager arranged for a book to record these details to be made available for staff. The meals are prepared by a carer which at the time of the first visit meant that only one carer was present to provide care for the thirteen service users, two of whom were in bed in their rooms. The kitchen is situated next to the dining room and lounge and the carer said that she could see what was happening while in the kitchen. This did however mean that she was unable to interact with the service users while working in the kitchen. One of the carers said that only carers who have received training in food hygiene were able to prepare meals for service users. Training certificates were on display in the kitchen. The registered manager said that she often took responsibility for the meals but had not arranged for additional staff to cover while she was away on leave. She also said that she was looking to recruit someone to prepare the lunch and possibly to assist with activities to assist the carers. Avondale Lodge Care Home DS0000043118.V311841.R01.S.doc Version 5.2 Page 16 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 and 18 Quality in this outcome area is good. The judgement has been made using available evidence including visits to the service. Service users feel that complaints will be taken seriously and acted upon and they are protected by staff awareness for the prevention of abuse. EVIDENCE: The registered manager said that no complaints had been received by the home since the last inspection. The home has a complaints policy in place that states the person who will investigate the complaint and timescales for the process. A resident said that if they had any concerns they would speak with the registered manager whom they felt would ‘listen and sort it out’. Staff had received training in the prevention of abuse during induction and NVQ training. The registered manager said that she and one of the carers had also attended additional training sessions in the protection of vulnerable adults. A carer spoken with was aware of the procedures to follow should abuse be suspected. Avondale Lodge Care Home DS0000043118.V311841.R01.S.doc Version 5.2 Page 17 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 and 26 Quality in this outcome area is good. The judgement has been made using available evidence including visits to the home. Avondale provides a clean, safe and homely environment for those who live and visit there. EVIDENCE: Since the last inspection an extension to the property has been built to provide five more bedrooms, nine en-suites, one new bathroom and toilet and enlarge the lounge and dining room. A front entrance with sitting area has also been created and the kitchen has been refitted and equipped. An enclosed garden and patio area has been provided to the rear of the property. The home looked clean, bright and homely. The large lounge with dining room has windows that overlook the rear garden, making the communal rooms light and airy.
Avondale Lodge Care Home DS0000043118.V311841.R01.S.doc Version 5.2 Page 18 Service users rooms contained many personal items such as ornaments, pictures and photographs. Many of the rooms have been redecorated since the last inspection and three service users spoken with said that they liked their rooms with one saying that they ‘had everything they wished’. One service user had a room with two steps up to the en-suite facilities that required risk assessing to ensure the person was not at risk attempting the steps when alone. Accommodation is provided on two floors with stairs and a passenger lift giving access to each floor. The kitchen and laundry room that are domestic in style, looked clean and in good order. Staff were seen to wear disposable aprons and gloves as necessary and had received training in infection control during their induction. Visitors to the home are admitted by a member of staff and are required to sign the visitor book on entering and leaving the premises. Avondale Lodge Care Home DS0000043118.V311841.R01.S.doc Version 5.2 Page 19 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, 28, 29 and 30 Quality in this outcome area is adequate. The judgement has been made using available evidence including visits to the home. Staff receive the training required to do their jobs and the registered manager is addressing the staffing levels to ensure all service user’s needs are met. It was not possible to confirm that Criminal Records Bureau and Protection of Vulnerable Adults checks had been completed for all staff, as the paperwork was not available in the home. EVIDENCE: As previously stated in standard 15, two carers were on duty at the time of the first visit to the home. On the second visit the registered manager was also on duty. Staff are responsible for the catering and domestic duties in the home as well as caring for the thirteen service users, currently resident at the home. The registered manager said that she does quite a lot of the cooking and cleaning for the home. Carers spoken with said that they felt able to cope with the catering and a visitor also said that she had no concerns over staffing levels. A service user said that staff were very kind and caring and were there when needed. The registered manager said that she was looking to recruit additional staff for catering duties and also possibly for assistance with the activities programme. Avondale Lodge Care Home DS0000043118.V311841.R01.S.doc Version 5.2 Page 20 Staff at the home said that they were encouraged and supported by the registered manager to attend training courses and obtain qualifications. Seven of the nine care staff employed hold or are in the process of obtaining NVQ level 2 or above in care. All new staff members undertake an induction programme that is in line with Skills for Care. Records seen indicated that the induction programme covers many aspects of care provision including infection control and health and safety. All staff had received training in moving and handling in June 2006 and four carers had attended training sessions in food hygiene during Sept 2006. The registered manager and two care staff members had received training in dementia care. The registered manager said that places were being arranged for four more staff to attend training sessions that are were held at a local college. Recruitment records were seen for three staff members. Two of the files contained the information required including two written references and proof of identity. However the third file only contained one sheet of paper with very limited information such as name and address of the person. The registered manager said that the paperwork had been obtained but was currently at another care home that was the umbrella organisation for Criminal Records Bureau checks. The registered manager also said that the CRB checks had been completed but there was no written confirmation for this. The registered manager attempted to contact the person holding the paperwork at the other home but they were unavailable. The registered manager agreed that the information must be returned to the home while CRB and POVA checks were being undertaken and should only go to the other home on a very short- term basis to be checked or arrangements would be made for the checks to take place at Avondale. Avondale Lodge Care Home DS0000043118.V311841.R01.S.doc Version 5.2 Page 21 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, 35, 36 and 37 Quality in this outcome area is good. The judgement has been made using available evidence including visits to the service. The home is run in the best interests of the service users and the safe working practices operated in the home protects them. The registered manager is addressing issues regarding the safety of service users financial interests and staff supervision. EVIDENCE: The registered manager is a qualified nurse who has fifteen years experience in the care sector. Mrs Wendy Osman has been the owner, along with her husband, of the home for three years. She holds NVQ level 4 in management and is registered with the commission.
Avondale Lodge Care Home DS0000043118.V311841.R01.S.doc Version 5.2 Page 22 Mrs Osman said that she was aware of the issues with care plans and risk assessments but that she had been very involved in caring for service users welfare during the building of the extension and had not allowed sufficient time to complete paperwork. Mrs Osman said that she was considering giving more responsibility to an experienced carer in assisting with care plans and staff supervision. Staff spoken with said that they received good support from the Mrs Osman. Service users and a visitor said that they found the registered manager easy to talk with and one service user said that she was ‘very caring’. The registered manager said that she has an open door approach to management and that service users, staff and visitors were able to approach her at any time. Mrs Osman said that a review of the care provided was discussed when the trial period after admission had been completed and that relatives frequently visited the home and had opportunity to give their views on the quality of care given at the home. A survey in the form of a simple questionnaire had been used at the beginning of the year to obtain the views of service users about life at the home. The registered manager said that feedback was given in one to one meetings. Service users spoken with all said that they would talk with the registered manager if they had any concerns about their care. The registered manager said that formal staff meetings had not been held but informal discussions took place to discuss issues such as changes to procedures in the home. Minutes had not been taken of the meetings. A carer confirmed that informal meetings took place. Staff were not receiving regular formal supervision at least six times a year as required. The registered manager said that she was in the process of arranging meetings and paperwork was seen that was to be used to record supervision sessions. The home holds small amounts of personal money for service users. The money is held securely and receipts are kept for all transactions. Records seen for four service users did not match the amounts held. Three records indicated that the amount held was more than recorded while one was seven pounds less than documented. The registered manager said that she would audit the accounts and investigate any discrepancies. Staff had received training in health and safety and during the visits staff were seen to use safe working practices while caring for service users. Hazardous substances such as cleaning fluids were stored securely. Information sheets had been obtained and were available for staff on the hazardous substances used in the home. Avondale Lodge Care Home DS0000043118.V311841.R01.S.doc Version 5.2 Page 23 The Fire Safety Officer had undertaken an inspection on the 15th September and the home was found to be satisfactory. A full evacuation exercise had been held on the 12th September 2006. The registered manager said that actions were being taken to address issues raised during the evacuation such as shelter and seating for service users when out of the building. Fire records seen were not up to date and it was not possible to confirm that five staff members had attended a fire drill in the last year. Following the inspection visits the registered manager contacted the inspector to confirm that all staff had now attended fire drills. Avondale Lodge Care Home DS0000043118.V311841.R01.S.doc Version 5.2 Page 24 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 3 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 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 3 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 x 2 2 x 3 Avondale Lodge Care Home DS0000043118.V311841.R01.S.doc Version 5.2 Page 25 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 OP7 Regulation 15 (2) Requirement The registered person must ensure that care plans are reviewed in consultation with the service user or if appropriate a relative/representative, to reflect the changing needs of the service users. The registered person must ensure that risk assessments are undertaken and kept under review for all service user’s daily living and social activities. The registered person must review the staffing levels to ensure the service users needs are met. The registered person must ensure that staff records, including confirmation of CRB and POVA checks, are kept available at the home. The registered person must ensure that staff receive supervision at least six times a year. Timescale for action 30/11/06 2. OP7 13 (4) 30/11/06 3. OP27 18(1) 30/11/06 4. OP29 17(2) Schedule 4 18(2) 30/11/06 5. OP36 31/12/06 Avondale Lodge Care Home DS0000043118.V311841.R01.S.doc Version 5.2 Page 26 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.V311841.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Lodge Care Home DS0000043118.V311841.R01.S.doc Version 5.2 Page 28 - 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!
