Inspection on 12/01/07 for Avondale Residential Care Home

This inspection was carried out on 12th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 Residential Care Home 16/12/08

Avondale Residential Care Home 16/02/06

Avondale Residential Care Home 30/08/05

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Avondale Residential Care Home 45 Norton Road Stourbridge West Midlands DY8 2AH Lead Inspector Christine Lancashire Key Unannounced Inspection 12th January 2007 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 Residential Care Home DS0000064415.V326882.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 Residential Care Home DS0000064415.V326882.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Avondale Residential Care Home Address 45 Norton Road Stourbridge West Midlands DY8 2AH 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) 01384 442731 Stoneleigh Care Homes Ltd Kelly Bate Care Home 15 Category(ies) of Old age, not falling within any other category registration, with number (15) of places Avondale Residential Care Home DS0000064415.V326882.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th February 2006 Brief Description of the Service: Avondale, which is on a main road near Stourbridge, is a fifteen bedded home accommodating older people. The home has been adapted and extended for this purpose from a traditional property in its own grounds with mature gardens and car parking available. The facilities include 15 single bedrooms (10 with en-suite), two communal lounges, a dining area, one assisted bathroom, one shower and four communal toilets. A shaft lift is also available for access to the first floor. Staffing is available over a 24hr period (this includes waking night staff) with seventeen staff including a registered manager, care staff and a housekeeper, cook and handyman. The home is registered for personal care only. The home offers a homely environment in which personal care is provided to older people without other substantive needs outside of frailty that is a result of the ageing process. The current resident group is of mixed gender and all white European. The home has a clear policy on not offering emergency care. The average fees at this home are £336.00 per week. Avondale Residential Care Home DS0000064415.V326882.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place on a weekday. The manager provided written information relating to the home and the residents, their relatives and visiting professionals completed questionnaires. During the inspection, the inspector viewed records, toured the building and spoke with several residents and staff. What the service does well: What has improved since the last inspection? What they could do better: The owner and manager continue to develop the home, using the quality assurance system to identify areas of change. They have considered the future provision and have initiated discussion with the inspector on this subject. Staff will need to receive further training should the home consider catering for more dependent residents. Avondale Residential Care Home DS0000064415.V326882.R01.S.doc Version 5.2 Page 6 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 Residential Care Home DS0000064415.V326882.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Avondale Residential Care Home DS0000064415.V326882.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,5 Quality in this outcome area is good. Residents are provided with suitable information about the home. Their needs are assessed prior to admission to the home and they are assured that these will be met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Statement of Purpose reflects the present conditions at the home. The needs of prospective residents are assessed prior to admission. The manager and an owner visit the prospective resident and also seek information from the carers and any relevant medical professionals. Should they be able to meet the person’s needs, the prospective resident is invited to visit the home and spend some time sampling the atmosphere and meeting the residents. On the day of the inspection, a relative was visiting the home to make enquiries about the possibility of admitting a prospective resident. The staff showed her round the home and the manager spent time explaining the conditions and next steps. Avondale Residential Care Home DS0000064415.V326882.R01.S.doc Version 5.2 Page 9 Records were examined in relation to the last person admitted and these contained relevant details of their needs and how these would be met by the home. This home does not take emergency placements nor does it admit people with a high level of physical dependency. Avondale Residential Care Home DS0000064415.V326882.R01.S.doc Version 5.2 Page 10 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 excellent. Residents’ needs are set out in a plan, which is implemented by staff. Medication is stored and administered in an appropriate way, according to suitable policies and procedures. Residents are treated with respect. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each resident has an individual plan which is drawn up using information gained during the assessment process and added to when observations are made or when the resident or a relative provides further details. These plans cover various aspects of each resident’s life. They are prepared on the computer and so can be altered easily when circumstances change. The health needs of sampled residents were recorded in plans. Tissue viability and nutritional assessments are carried out at the time of admission and updated periodically Residents are also weighed on a monthly basis. Details of visits from health professionals indicated that residents have appropriate access to a range of services. Avondale Residential Care Home DS0000064415.V326882.R01.S.doc Version 5.2 Page 11 There are suitable arrangements for the storage and administration of medication. Records were up to date and complete. The medication system is overseen by a pharmacist who makes regular visits and whose last report was made available. Staff who administer medication are suitably trained. Residents confirmed that they are treated by respect. They have good access to the manager and owner and staff have time to spend talking with them. Avondale Residential Care Home DS0000064415.V326882.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. Quality in this outcome area is excellent. Residents find that the lifestyle at this home matches their preferences and meets their needs. They maintain contact with family, friends and their local community. They are enabled to exercise control over their lives. Residents enjoy an appealing and varied diet in pleasant surroundings. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents are encouraged to voice their preferences in terms of daily activity and association. Their interests are recorded at the time of admission and staff make efforts to ensure that they are enabled to follow previous interests and explore new ones. One of the living rooms is quiet in the day so that residents can read or chat. There is a radio and television in the other room. The home uses the services of a variety of visiting workers to lead sessions in physical activity and crafts. Staff also encourage residents to participate in games, such as bingo, skittles, dominoes and board games. In the Summer months, residents enjoy the garden. Trips to places of interest, such as the safari park and garden centres, have been organised in the past, but most of the residents now prefer to avoid long journeys. They enjoy occasional pub Avondale Residential Care Home DS0000064415.V326882.R01.S.doc Version 5.2 Page 13 meals and musical entertainers. Prior to Christmas, residents enjoyed a trip to a garden centre, a meal in a local pub and visits from carol singers. Some residents visit relatives or friends. They are encouraged to make choices about the activities at the home on an individual basis and at residents’ meetings. The right of residents to choose to rest and not to participate in organised activity is respected. The inspector spoke with two residents who explained that they prefer to spend most of their time in their rooms. The home has a policy on maintaining the involvement of relatives, friends and representatives. This is on display in the foyer to the home. Visiting is not restricted, but visitors are asked to avoid arriving at mealtimes. In survey responses, relatives confirmed that they are made welcome by staff. Visitors may be entertained in service users’ rooms in addition to the two lounges and dining room. The garden is also available in the warmer weather. The home encourages residents to make their own arrangements for handling their finances. Contact numbers for advocacy services and external agencies are made available to service users and their relatives. Residents are enabled to bring personal possessions with them and many have chosen to bring small items to make their rooms more individual. The home has some storage space, should a resident wish to replace an item of furniture for one of their own. This would be agreed prior to admission. Residents are able to access their records and signatures on files indicate that they are encouraged to participate in the care planning and review process. The home offers three meals a day to residents, with some also choosing to take supper as well. Breakfast is served between 8 and 9.30am and includes a full choice of cold and cooked foods. Those who choose not to come down stairs for breakfast may have a tray in their room. There is a set menu at lunchtime, but the menu is written on a board the day before. The preferences and medical needs of individuals are known by staff and alternatives are prepared after consultation. There are hot and cold choices at tea-time. The menus show a variety of traditional English meals in accordance with the cultural background of the residents. The home has offered multi-cultural alternatives from time to time, but these are not popular. Survey responses indicated that residents are pleased with the standard of catering and residents praised the catering on the day of the inspection. All service users are assessed at the time of admission and the staff monitor weight loss and gain, so that appropriate referrals can be made to health professionals in case of unusual or concerning variations in this respect. Avondale Residential Care Home DS0000064415.V326882.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18. Quality in this outcome area is excellent. Residents’ and their representatives are confident that their complaints will be treated seriously and acted upon. The legal rights of residents are protected and there are good arrangements to protect residents form abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There are good arrangements for handling complaints and these are well publicised. The home maintains records of complaints which have been made, together with details of how they have been handled and the outcome. Few complaints are made. The manager shared the details of recent complaints with the inspector and this demonstrated that the manager had taken care to explore the reason for the complaint and to make arrangements so that the person who complained was satisfied with the outcome. Residents’ legal rights are protected at this home. Residents’ are encouraged to register so that they may vote and the manager produced evidence that they had done so. There are policies and procedures to enable staff to protect residents’ from abuse. Staff receive training in this area and this is renewed on a regular basis. Appropriate checks are made on all staff at the time of recruitment and they sign disclaimers each year to confirm that they have not offended. Professional visitors are asked for identification and other visitors are monitored by means of a signing-in book. Avondale Residential Care Home DS0000064415.V326882.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,23,24,25,26. Quality in this outcome area is excellent. Residents live in a clean, safe, comfortable home, with sufficient facilities and their own possessions in their rooms. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The building is clean and well maintained throughout. One relative wrote, ‘The home is always clean and well kept’. There are no unpleasant odours. There are two communal rooms, so residents can choose to sit in a quiet room. There are sufficient WCs and bathrooms which are kept clean. Improvements have been made so that there is now a more accessible shower on the ground floor in addition to the assisted bath on the first floor. Sampled bedrooms were homely and three residents showed the inspector their comfortable rooms with many personal items. The garden is accessible and has plenty of furniture. Residents enjoy sitting in the garden in the warmer weather. Avondale Residential Care Home DS0000064415.V326882.R01.S.doc Version 5.2 Page 16 There are suitable arrangements for the storage of cleaning materials and other chemicals. The home does not have a sluice facility, but there is a suitable setting on the washing machine. The needs of the present residents are not such that a sluice is required, but this provision will need to be made, should the registration category change to include more dependent residents. Avondale Residential Care Home DS0000064415.V326882.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. Quality in this outcome area is good. The residents’ needs are met by sufficient staff who are suitably checked and trained and who receive a good level of support and supervision. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff are recruited through a standard process and all appropriate checks are made. The records of the most recent recruit showed that references and a Criminal Records Bureau check had been obtained prior to appointment. There is a basic induction during the first week of employment. Further skills are covered during the induction period. There is a checklist for monitoring this period and monthly appraisals are carried out for the first three months of employment. The rotas show a good level of staffing which exceeds the minimum level required. Rotas are drawn up on a six monthly basis, so that personal commitments can be taken into account. The manager prefers to use the services of regular staff to cover in times of staff shortage, but some use has been made of agency staff. There is a senior member of staff on each shift and the manager and deputy work alternate weekends. Residents confirmed that the staff are helpful. One relative wrote, ‘I have always found the staff very helpful and accommodating’…another wrote, ‘staff are always very polite and welcoming when you visit’. Avondale Residential Care Home DS0000064415.V326882.R01.S.doc Version 5.2 Page 18 The deputy manager is responsible for coordinating training in the staff team. All staff receive induction training and in-house training is supplemented by outside trainers who lead the mandatory courses. There is a good system for ensuring that all staff renew basic training and receive opportunities to develop their skills and knowledge in other areas. All staff receive regular supervision and appraisal. A questionnaire is distributed prior to appraisals and this helps to keep the sessions focussed. There are regular staff meetings. In addition, the owners and manager are available for informal discussion on a daily basis. Avondale Residential Care Home DS0000064415.V326882.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38. Quality in this outcome area is excellent. Residents’ live in a home which is run by a manager who is fit, of good character and able to discharge her responsibilities fully. The home is run in the best interests of residents so that their health, safety and welfare are promoted and protected and their and their financial interests are safeguarded. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Registered Manager is suitably qualified and experienced to run the home. She has completed the Registered Managers’ Award and has improved her IT skills. She is diligent in her duties and works hard to ensure that the high standards are maintained. There are clear lines of responsibility in the staff team and suitable arrangements for cover in the absence of the manager. The Avondale Residential Care Home DS0000064415.V326882.R01.S.doc Version 5.2 Page 20 home has a quality assurance system which is used to maintain the standard of care. This involves questionnaires which are sent to all interested parties including the residents’ and visiting professionals. Policies and procedures are reviewed regularly. The home has an annual development plan and a business plan. The home does not act as an appointee or agent for any service users. Service users make their own arrangements for the handling of their finances. However, the home does look after some small amounts of spending money on behalf of residents’. There are procedures which govern the handling of this money. Individual amounts of money are stored securely, with full records of deposits and withdrawals. These records were seen to be appropriately recorded. The manager checks the records on a regular basis and signs to indicate this. Inventories of service users’ property are completed at the time of admission to the home. The home has a written statement of the policy, organisation and arrangements for maintaining safe working practices. All accidents are recorded. Dates were provided for the full range of safety checks on equipment in and services to the home. Staff are provided with training in safe working practices and equipment for infection control is freely available at the areas of frequent use. There are risk assessments in relation to the individual service users, the building, working practices and fire. These are reviewed and updated on a regular basis. The inspector sampled the risk assessments and the safety records and found these to be up to date and in good order. The physical environment is well maintained and any possible hazards, such as steps, are well marked. Staff are also aware of the need to provide verbal warnings to visitors. There are aids and adaptations in bathrooms and WCs to enhance personal safety. There are weekly visits by the handyman, who attends to minor repairs and decorates all areas on a regular basis. Avondale Residential Care Home DS0000064415.V326882.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 3 4 X X X 3 4 4 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 4 X 4 X 3 X X 3 Avondale Residential Care Home DS0000064415.V326882.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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 Residential Care Home DS0000064415.V326882.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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 Residential Care Home DS0000064415.V326882.R01.S.doc Version 5.2 Page 24 - 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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