CARE HOMES FOR OLDER PEOPLE
Avondale Lodge Hythe Road Marchwood Southampton SO40 4WT Lead Inspector
Tracey Box Unannounced 31.08.05 9:30am 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 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 H54 S43118 Avondale Lodge V244803 310805.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Avondale Lodge Address Hythe Road, Marchwood, Southampton, SO40 4WT 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) 023 8066 6534 Mrs W Osman & Mr G Osman Mrs W Osman CRH 9 Category(ies) of OP- 9; DE(E) - 9; MD(E) - 9 registration, with number of places Avondale Lodge H54 S43118 Avondale Lodge V244803 310805.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: N/A Date of last inspection 03.02.05 Brief Description of the Service: Avondale Lodge is a registered care home providing opersonal support and accommodation for up to nine older people. The home is privately owned 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, parking is to the rear of the home. Avondale Lodge H54 S43118 Avondale Lodge V244803 310805.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The unannounced inspection took place over five hours, Mrs Wendy Osman, the manager, assisted the inspector during the inspection. The people living at Avondale Lodge prefer to be referred to as service users, therefore will be referred to as this throughout the report. At the time of the inspection nine service users lived at the home. The manager showed the inspector the layout within and surrounding the home. The majority of the internal decoration and furnishings are worn, paintwork is flaking, however, the provider has applied for a major variation to the Commission for Social Care Inspection to extend the property, this work will include renovation and refurbishment to the existing building. The inspector witnessed good interacting between service users and staff. Records were seen and the inspector asked service users, staff and relatives for their views and experiences of living at Avondale Lodge, all responded positively about the care and support received. One visitor said “I am always made welcome here. ” One resident said “I moved here a few weeks ago, I feel very settled here, this is my home now.” What the service does well:
The home benefits from the manager, who is also the provider, who works closely with staff, service users and relatives. The home regularly reviews aspects of its performance through seeking the views of service users, relatives/visitors and staff. Should the home have a vacancy in a double bedroom, part of the assessment process ensures prospective service users are fully informed of the fact that two people are required to accommodate that bedroom. The service users occupying the double bedrooms are happy to share. The inspector received comment cards from nine service users and two relatives/visitors, all expressed their overall satisfaction at the service provided by the staff and manager of the home. Avondale Lodge H54 S43118 Avondale Lodge V244803 310805.doc Version 1.40 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Avondale Lodge H54 S43118 Avondale Lodge V244803 310805.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Avondale Lodge H54 S43118 Avondale Lodge V244803 310805.doc Version 1.40 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 The homes procedure for assessing prospective service users is good, documentation shows the procedure is followed. EVIDENCE: The inspector saw the homes assessment procedure and a pre admission assessment that was completed prior to a service user’s admission. The manager explained she visits the prospective service user to assess their needs, this meeting may include family, representatives and social workers/health care professionals where necessary, all contribute to complete the pre admission assessment. One service user recalled the manager visiting them prior to their admission to complete the pre assessment paperwork, the service user explored their assessment with the inspector, the service user agreed that the information written on the pre admission assessment was discussed at their meeting prior to their move into the home. The manager said relatives/representatives of the prospective service user are welcome to visit the home. One relative confirmed they did visit the home on a number of occasions prior to their relative moving in.
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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 standard(s) 7,9 Service users health, personal and social needs are set out in individual’s care plans, however risk assessments have yet to be fully established. Service users are protected by appropriately trained staff, who follow the homes policies and procedures for dealing with medicines. EVIDENCE: The information held in the individuals care plans was detailed, enabling service users to be cared for appropriately. The inspector explored their care plans with two service users, both service users agreed with the contents and confirmed their involvement in compiling them. Records showed care plans had been reviewed on a monthly basis or sooner if necessary. There were limited risk assessments in place to ensure the safety of service users and staff. Risk assessments must be completed on all areas that are necessary to protect service users and staff. This is a repeat requirement from a previous inspection, 03/02/05. Avondale Lodge H54 S43118 Avondale Lodge V244803 310805.doc Version 1.40 Page 11 At the time of the inspection, staff administer all of the service users medication using a monitoring dosage system, staff told the inspector that service users prefer them to store and administer service users medication for them, one service user told the inspector this was their wish. The inspector saw medication being correctly administered, staff followed the homes medication policy and procedure, ( the home uses the monitoring dosage system and monitoring administration record sheets) the records kept in conjunction with medication received and returned to the pharmacist were correct. Records of all staff trained to administer medication were found to be in order. Avondale Lodge H54 S43118 Avondale Lodge V244803 310805.doc Version 1.40 Page 12 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13 Contact with family/friends/representatives and local community is encouraged as the individual wishes. EVIDENCE: A record of visitors to the home was seen, which showed family visits, the inspector talked to one visitor who expressed their happiness with the care and support their relative receives. Transport to enable residents to attend appointments is supplied by family members. The manager arranges an outing twice a year, usually in the Spring and just before Christmas, these outings have included visits to the Theatre, an Orchestra and the Hampshire Police band. Staff encourage service users to participate in activities such as dominos, cards, bingo and lounge bowls! if they want to. The manager confirmed the village offers the opportunity for activities, ‘whist’ club is held in the village hall, the junior school hosted a fireworks display last year, there are local shops, chemist, a bank and three pubs. One visitor arrived after lunch to take their relative to the pub. The inspector received two comment card which suggested “ I enjoy playing cards.”
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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 standard(s) 16 The home has a satisfactory complaints procedure in place with some evidence that residents feel that their views are listened to and acted upon. EVIDENCE: The service users and visitors were aware of the procedure, but have not felt the need to do so, they were confident the home would take appropriate action should a complaint be made. The inspector asked two service users if they had made a complaint in the past, both replied, “No, I haven’t felt the need to.” The inspector asked if they felt able to should the need arise, all responded “I am aware of what to do, and I feel the home would do it’s best to improve things should I need to complain, there are always staff on duty to speak to.” The inspector received nine service users comment cards prior to this inspection, all commented that they know who to speak to if they were unhappy. The inspector looked at the complaints log which had not had any entries for over a two years, the inspector asked the manager if complaints are being logged, the manager confirmed to her knowledge non had been made, as service users and visitors would see her. The inspector recommended that the pages of the log are numbered consecutively to show a true record of complaints received. Two visitors spoken with were aware of the procedure, but have not felt the need to do so ( this is also evident from the comment cards the inspector received prior to this inspection), they were confident the home would take appropriate action should a complaint be made.
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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 standard(s) These standards were not assessed on this occasion EVIDENCE: These standards were not assessed on this occasion Avondale Lodge H54 S43118 Avondale Lodge V244803 310805.doc Version 1.40 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 29 The arrangements for the recruitment, induction and training of staff are good, staff clearly demonstrate their understanding of their role and responsibility, however, some practices must be improved to ensure residents protection. EVIDENCE: The inspector saw evidence of the CRB disclosure being completed, however, there was no evidence of the disclosure being cleared, the manager investigated this and the inspector received a disclosure number which was clarified as genuine. The manager must ensure evidence of CRB clearance and checks against the POVA list (in line with the Data Protection Act 1998.) are documented on the individuals file. The manager explained the recruitment process and showed the inspector the homes written procedure. Three staff files were sampled, recruitment checks had been completed. The inspector saw the homes procedure for the induction of new staff, along with a written record of training received. Staff files included certificates of training completed. Avondale Lodge H54 S43118 Avondale Lodge V244803 310805.doc Version 1.40 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38 Residents health, safety and welfare are fully protected. EVIDENCE: Staff said they follow policies regarding health and safety. Staff training files were looked at and showed that all staff had received appropriate training. The home has adequate risk assessments for the building. The inspector viewed certificates for the servicing of systems, all of which were in order. Avondale Lodge H54 S43118 Avondale Lodge V244803 310805.doc Version 1.40 Page 18 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 x 15 x
COMPLAINTS AND PROTECTION x x x x x x x x STAFFING Standard No Score 27 x 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x x x x x x x x x 3 Avondale Lodge H54 S43118 Avondale Lodge V244803 310805.doc Version 1.40 Page 19 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 OP 7 Regulation 13 (4) Requirement Risk assessments must be completed on all areas that are necessary to protect service users and staff. THIS IS A REPEAT REQUIREMENT FROM 03/02/05 Evidence of each staff receiving clearenace of their enhanced CRB disclosue in line with the Data Protection Act 1998. Timescale for action 01/10/05 2. OP 29 19, Schedule 2 01/10/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 16 Good Practice Recommendations To number the pages of the complaints log consecutively to show a true record of complaints received. Avondale Lodge H54 S43118 Avondale Lodge V244803 310805.doc Version 1.40 Page 20 Commission for Social Care Inspection 4th Floor, Overline House Blechynden Terrace Southamption SO15 1GW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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