Inspection on 19/03/09 for Avondale Rest Home

This inspection was carried out on 19th March 2009.

CSCI found this care home to be providing an Adequate service.

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

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 10/07/2009.

CARE HOMES FOR OLDER PEOPLE Avondale Rest Home 38 Avondale Drive Leigh on Sea Essex SS9 4HN Lead Inspector Michelle Love Unannounced Inspection 19th March 2009 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 Rest Home DS0000071829.V374666.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 Rest Home DS0000071829.V374666.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Avondale Rest Home Address 38 Avondale Drive Leigh on Sea Essex SS9 4HN 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) 01702711934 01702711934 Avondale Rest Homes Ltd Miss Claire Louise Packer Care Home 19 Category(ies) of Dementia (19), Old age, not falling within any registration, with number other category (19) of places Avondale Rest Home DS0000071829.V374666.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care Home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP Dementia - Code DE The maximum number of service users who can be accommodated is 19 Newly Registered 2. Date of last inspection Brief Description of the Service: Avondale Rest Home is a care home for up to 19 older people and is additionally registered to admit people who have or may develop dementia. It is situated in a quiet residential area of Leigh-on-Sea and is in close proximity to local shops, amenities and transport links. Originally Avondale was two, two storey houses and over the years this has been renovated and extended for residential care purposes. The home has 13 single bedrooms and 3 shared rooms, all of which have ensuite facilities with the exception of one single bedroom, which is adjacent to a bathroom. The communal space within the home consists of a large lounge, spacious dining room and a conservatory. All areas of the home environment are well maintained and the home is in good decorative order. The Statement of Purpose details that the level of fees is between £450.00 and £520.00 per week, depending on the dependency levels of the individual resident and the size and location of bedrooms. Extra services such as hairdressing, chiropody, dental treatment etc are not included in the fees. Avondale Rest Home DS0000071829.V374666.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This was an unannounced key inspection. The visit took place over one day by one inspector and lasted a total of 9 hours, with all key standards inspected. This was the service’s first inspection since being newly registered in October 2008. Prior to this inspection, the registered provider/manager had submitted an Annual Quality Assurance Assessment. This is a self-assessment document required by law, detailing what the home does well, what could be done better and what needs improving. Information given in this document has been incorporated into this report. As part of the process a number of records relating to residents, care staff and the general running of the home were examined. Additionally a partial tour of the premises was undertaken, residents and members of staff were spoken with and their comments are used throughout the main text of the report. Several surveys for relatives, staff and healthcare professionals were left at the care home for distribution and for people to complete and return to us. At the time of producing this report no surveys had been returned to us. The inspection process was conducted primarily with both the registered provider/manager and the deputy manager. What the service does well: There is an open visiting system in place at the home, whereby people can visit their member of family and/or friend at any reasonable time. Visitors to the care home are made to feel welcome and are given a drink. Meals provided to people, are of a good quality and comments from residents relating to meals provided was positive. There is a varied menu and alternatives are available if required. The care home provides people with a safe and homely environment that meets their needs. Residents are encouraged to personalise their bedroom. The home is clean, tidy and smells fresh. Avondale Rest Home DS0000071829.V374666.R01.S.doc Version 5.2 Page 6 Residents have their social care needs met and there is a good choice of daytime activities available. The service promotes inclusion and fosters good relationships with neighbours and other members and/or groups within the local community. Admissions are not made to the home until a needs assessment has been undertaken and the management team of the home are confident that they have the skills and ability to meet the individual’s care needs. Rapport between residents and staff are positive and evidence showed that staff working at the care home, know the needs of individual people who live at Avondale. 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. The summary of this inspection report can be made available in other formats on request. Avondale Rest Home DS0000071829.V374666.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 Rest Home DS0000071829.V374666.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): 3. Standard 6 does not apply to this service. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People wanting to move into the home can expect to have their needs identified and met through a robust assessment process. EVIDENCE: There is a formal pre admission assessment format and procedure in place, so as to ensure that the staff team are able to meet the prospective persons’ needs. Admissions are not made to the home until a full assessment is undertaken. The pre admission assessment document was detailed and where appropriate additional information is sought from the individual’s placing authority and/or hospital. The manager stated that the majority of referrals to Avondale are from recommendations. The manager stated that assessments are primarily, undertaken by either herself or the deputy manager and with the assistance of another staff Avondale Rest Home DS0000071829.V374666.R01.S.doc Version 5.2 Page 9 member. Wherever possible the assessment is conducted with the resident and/or their representative. Admissions to the home only take place if the management team of the home are confident that the prospective person’s needs, can be met. People are given the opportunity to visit the home prior to admission, to meet staff and other people living at the home. The AQAA confirms the above and states, “both the manager and deputy manager arrange and meet with the prospective resident/relative/friend where possible. A detailed assessment is carried out which enables staff to be able to care for a new service user until their full care plan is in place”. We saw from looking at the care file for the newest person admitted to the care home, that the pre admission assessment was completed prior to the person’s admission and information recorded was detailed and informative. The home does not provide intermediate care, however on occasions people are admitted for periods of short-term respite. Avondale Rest Home DS0000071829.V374666.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 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People could be at risk of not always receiving care in the way that they would want, due to incomplete care plans and gaps in medication records. EVIDENCE: As part of this site visit, the care files for 3 people were randomly examined. These showed there is a formal care planning system in place to help staff identify the care needs of individual people and to specify how these are to be met by care staff. A plan of care was available for each person. Some elements of the care planning processes for individual people were seen to be detailed, informative and person centred pertaining to their physical, healthcare, emotional and social care needs. Avondale Rest Home DS0000071829.V374666.R01.S.doc Version 5.2 Page 11 However this is not consistent, and further development of the care planning and risk assessing processes are required, so as to ensure the care needs of individual people are clearly recorded and staff have the most up to date information to ensure appropriate levels of care delivery. The care file for one person detailed their individual strengths, personal preferences, likes and dislikes. For example information relating to their personal care preferences were clearly recorded detailing their choice to having a bath or shower, the numbers of staff required to provide support and assistance and information relating to the toiletries required and/or preferred by the person. Additionally there was good information recorded pertaining to the specific elements where the person was able to maintain their independence and where they required particular support from care staff. The same care file showed that over a short period of time the person’s weight had fluctuated and they had sustained a considerable weight loss. Whilst we acknowledge there was a detailed formal assessment in place relating to their dietary needs and the person’s weight was being monitored monthly, no plan of care or risk assessment was devised detailing how this was to be proactively managed and/or the risk minimised. On inspection of this person’s nutritional records, gaps were noted. Daily care records confirmed that the person had a poor dietary intake, however on some occasions there was limited evidence to show staff’s interventions. Records also detailed that the person was at risk of falls and that they had poor balance. A formal falls assessment was completed, however no manual handling assessment was compiled. The other care file examined included a manual handling assessment. This was detailed and comprehensive, recording specific risks, how to limit the risks, equipment to be used, numbers of staff required to undertake the task safely and evidence this had been reviewed and updated to reflect changes to the individual’s care needs. The care file for another person recorded them as suffering with depression on occasions, however no information was recorded detailing how this manifested and guidelines for staff as to what support was required to effectively support the individual. On inspection of daily care records, these showed that the person could become physically aggressive towards staff. No care plan or risk assessment was devised detailing how this was to be proactively managed and/or the risk minimised. Records also showed that the person on occasions refused to take their prescribed medication. No care plan or risk assessment was devised. Interaction between staff and people living at the home was seen to be positive. Staff assisted individual residents’ with due regard to their dignity and wellbeing. Staff spoken with, were able to demonstrate a good understanding and knowledge of individual people’s care needs and how they like to be supported. Throughout the day of the site visit, staff were observed to promote Avondale Rest Home DS0000071829.V374666.R01.S.doc Version 5.2 Page 12 people’s privacy and dignity e.g. knocking on people’s doors before entering, providing personal care in private, addressing people by their preferred name etc. People who live at the care home have access to a range of healthcare professionals and services as and when required. These include the continence advisory team, district nurse services, GP, community psychiatric nurses, dentist, optician, mental health consultants etc. The AQAA details there are good proactive working relationship between staff/management team of the home and the local GP surgeries. Medication practices and procedures were examined as part of this inspection. The medication trolley was secure and medication is stored safely. The temperature where medication is stored is not recorded and the manager was advised that this should be undertaken so as to ensure that medication is stored at the right temperature. The failure to keep medication at the right temperature could result in people receiving medication, which is ineffective. The manager has implemented an audit to identify discrepancies in medication recording. Records showed that some issues had been highlighted at the most recent spot check undertaken. However, on inspection of Medication Administration Records (MAR), records were not up to date, with gaps in recording and information. This refers specifically to no record of some medicines having been given to the resident when they were due, as the entries on the MAR record had been left blank and not signed/initialled by staff. Where a variable dose e.g. 1 or 2 tablets to be administered was recorded, the MAR record did not always identify the actual amount of medication administered. Where ‘O’ “other define” is recorded, the rationale for the code was not always recorded on the reverse of the MAR record. Where bottle and packets of medication are used, these should be signed and dated to indicate when medication is commenced. The care records for one resident showed that with staff guidance, they are enabled to administer their own insulin. The deputy manager was observed administering medication to residents at lunchtime. They were seen to administer medication to residents with regard to their dignity and personal choice; however there were occasions whereby the medication trolley was left open and unattended and medication was easily accessible. This is poor practice and potentially, places people at risk and requires reviewing. Following discussions with 4 members of staff, all were aware of the procedures and practices that need to be undertaken in relation to the safe administration of Alendronic Acid and Risedronate. Avondale Rest Home DS0000071829.V374666.R01.S.doc Version 5.2 Page 13 The AQAA details that medication reviews for people were carried out between October and December 2008. Records showed that staff who administer medication have up to date training, however there is no assessment to show that staff remain competent to administer medication safely and it is recommended that this be reviewed. Avondale Rest Home DS0000071829.V374666.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service can be assured that their social care needs will be met and that they will receive a varied diet. EVIDENCE: An activities co-ordinator is employed at Avondale between 10.30 a.m. and 3.30 p.m. on Monday, Tuesday, Wednesday and Friday, however these hours are flexible to cover events held during the evenings and at weekends. A record is maintained for each person identifying hobbies and interests and actual activities undertaken. A varied programme of activities is available for people at the care home and includes 1-1 chats, sing-a-long, balloon and ball games, gentle exercises, manicures and hand massage, quizzes, board games and jigsaws, reminiscence, bowls, bingo, movies, arts and crafts, skittles, religious observance and external entertainers. A programme of activities is displayed within the dinning room. Residents spoken with confirmed that they enjoy the activities provided and have the option as to whether or not they participate. Avondale Rest Home DS0000071829.V374666.R01.S.doc Version 5.2 Page 15 People who use the service are encouraged and enabled to develop and maintain personal and family relationships. There is an, open visiting policy in force at the home, whereby residents can have visitors at any reasonable time. As part of the inspection process the delivery of the lunchtime meal to people at the home was observed. A menu board detailing the choice of meal available was evident. Tables were attractively laid with tablecloths, tablemats, cutlery, napkins, condiments and vases of flowers. Portions of food were observed to be attractively served and in sufficient quantities. Where people require assistance, people were seen to be provided with appropriate support that was both sensitive and respectful. One person who has a sensory impairment was advised by the member of staff serving the meal of where specific food items were on their plate, making it easier for them to locate particular food. This was undertaken by the staff member with sensitivity and so as not to draw attention to the individual person. Comments from people at the home in relation to the quality of meals provided were positive and included, “the food is very good” and “yes, I like the food”. People also confirmed that they have a choice of where they wish to eat their meals. Avondale Rest Home DS0000071829.V374666.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People can be confident that any concerns raised will be dealt with effectively and acted upon. People can expect staff to respond appropriately to allegations of abuse. EVIDENCE: There is a complaints policy and procedure in place and this is detailed within both the Statement of Purpose and Service Users Guide. Both documents need to be amended to reflect that we no longer investigate complaints. The AQAA details that staff are required to read the above policy and sign as an acknowledgment of their understanding. Staff spoken with demonstrated a good understanding of the above procedures. Records showed that since the change of ownership, there have been no complaints. People spoken with confirmed that they feel listened to and if issues are raised feel confident to discuss these with members of staff and the management team. The manager advised that as a management team they are open to feedback and/or criticism and strive hard to deal with any issues promptly and to ensure a positive outcome. Records of compliments were readily available and comments included, “To [name of manager] and all the staff, we would like to say a big thank you for all the care and love you gave to our member of family, especially [name of Avondale Rest Home DS0000071829.V374666.R01.S.doc Version 5.2 Page 17 staff], we are very grateful to you all” and “I cannot thank you enough for all your kindness and affection you have shown to [name of resident] during the 2 years they lived with you and especially during their last few weeks. They could not have received more concerned caring had they been at home”. Since being newly registered no safeguarding referrals have been raised. Staff spoken with, demonstrated a good awareness and understanding of safeguarding procedures and advised that should an issue arise, information would be passed to the person in charge of the shift and/or the manager and deputy manager. A random sample of 6 peoples’ training records were inspected and these showed that 5 out of 6 people had evidence of having undertaken safeguarding training. On inspection of the, staff training plan for 2008-2009, this showed that all staff working at the care home have safeguarding training. The manager advised that further safeguarding training for staff is planned during 2009. Avondale Rest Home DS0000071829.V374666.R01.S.doc Version 5.2 Page 18 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 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People can expect to live in a home that is comfortable, safe and clean and which meets their needs. EVIDENCE: A partial tour of the premises was undertaken with a senior member of staff during the morning of the site visit. The home was observed to be homely and comfortable for the people who live there. The communal space within the home consists of a large lounge, spacious dining room and a conservatory. There are 13 single rooms (12 have en-suite facilities) and 3 shared bedrooms (with en-suite facilities). A random sample of residents’ bedrooms, were inspected and all were observed to be personalised and individualised with many personal items on display. Avondale Rest Home DS0000071829.V374666.R01.S.doc Version 5.2 Page 19 Since being newly registered, the registered provider/manager has commenced a refurbishment and redecoration programme at the home. Improvements to the home environment have included, new flooring and carpets laid within some areas of the home, redecoration of some residents bedrooms, refurbishment and redecoration of the dining room, decoration of the lounge, conservatory and hallways and the purchase of new equipment e.g. cooker, boiler, washing machine and tumble drier. The AQAA details that within the next 12 months it is hoped for the laundry room to be re-tiled and the general storage areas to be tidied up. No health and safety issues were highlighted as part of this site visit. A maintenance book is available within the home and this shows areas within the home environment, which require work to be undertaken. A maintenance person is employed at the home Monday to Wednesday between 1.00 p.m. and 6.00 p.m. A random sample of safety and maintenance certificates were inspected. Records showed equipment had been serviced and remains in date until their next examination. We were advised by the manager that a new fire alarm system is to be fitted in the future. Avondale Rest Home DS0000071829.V374666.R01.S.doc Version 5.2 Page 20 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 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who live at the home can expect to be supported by staff who have sufficient skills and knowledge to meet their needs, however there maybe insufficient staff on duty to meet their needs. EVIDENCE: The manager confirmed that staffing levels at the home are 4-5 members of staff between 08.00 a.m. and 14.00 p.m., 3 members of staff between 14.00 p.m. and 20.00 p.m. and 2 waking night staff between 20.00 p.m. and 08.00 a.m. each day. In addition to the above, ancillary staff are utilised at the home (cook and domestic). The manager’s hours are supernumerary to the above and the deputy manager is employed 4 days a week (some of which are supernumerary shifts). On inspection of 4 weeks staff rosters, records showed that staffing levels as detailed above have not always been maintained. We have not received any Regulation 37 notifications advising us of the staffing shortfall and measures undertaken to deploy staff to the home. The AQAA details under the heading of ‘what we do well’, “we provide a ratio of staff which is resourceful, and in line with our current dependency of service users. We adapt this ratio when dependency increases/decreases accordingly”. Whilst we recognise that staffing levels may be adjusted to take into account individual people’s Avondale Rest Home DS0000071829.V374666.R01.S.doc Version 5.2 Page 21 dependency levels, no evidence was available to show the rationale for the decision and/or change in staffing levels on any given day. Additionally we are mindful that the manager or deputy manager may have assisted and provided cover where there was a staffing shortfall, however the roster does not reflect this. Additionally the rosters evidenced that in one week, one member of staff worked a total of 67 hours, another member of staff worked a total of 16 hours (16.00 p.m. to 08.00 a.m.) and on some occasions staff have been rostered as the designated cook and as a carer on the same shift. The staff files for 4 people were examined and included records for those people newly employed. The majority of records as required by regulation were available, however the staff file for one person showed that one of their written references was received after they commenced employment and there was no record of them having received an induction. Induction records were available for other staff members, case tracked and these were seen to be detailed and comprehensive. Several members of staff have worked at Avondale for many years and agency staff are not used, however should the need arise agency staff would be deployed. The training plan for 2008-2009 details that 9 members of staff have attained NVQ Level 2, 6 members of staff have attained NVQ Level 3 and the manager has attained NVQ Level 4 in management. The AQAA details that 2 members of staff are currently working towards their NVQ Level 2 and 2 people are to commence NVQ Level 4 in care management. The training plan for 2008-2009 showed the majority of staff had attained training relating to core subject areas such as first aid, health and safety, moving and handling, fire safety and infection control. Gaps were noted pertaining to moving and handling and food hygiene for some people. On inspection of 6 people’s files, training records showed that staff had received varied training for those conditions associated with the needs of older people e.g. dementia awareness, diabetes, stoma care, epilepsy awareness, nutritional care in the elderly, catheter care, dealing with challenging behaviour etc. The manager advised that additional training is planned for 2009 in both core and specialist subject areas. A number of training DVD’s (infection control, dementia awareness, fire awareness, food hygiene and health and safety) have been purchased to enhance externally sourced staff training. Staff spoken with stated that the management team are very proactive in promoting and encouraging staff to undertake training. Avondale Rest Home DS0000071829.V374666.R01.S.doc Version 5.2 Page 22 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, 36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People can expect to live in a care home that has a positive culture and operates to meet individual needs but to ensure they are safe identified risks need to be managed appropriately. EVIDENCE: This service was newly registered with us on 10th October 2008. The registered provider/manager was the manager of Avondale under previous ownership. From discussions with the manager we were advised that they have over 14 years experience working with older people, both as a carer/senior carer and within a management role. The manager has achieved NVQ Level 2, 3, 4 in Care Management and completed the Registered Managers Award in March 2009 and is awaiting her certificate. Avondale Rest Home DS0000071829.V374666.R01.S.doc Version 5.2 Page 23 The Statement of Purpose details, “Avondale Rest Home aims to provide service users with a secure, relaxed and homely environment in which, their care, well being and comfort is of prime importance. Carers will strive to preserve and maintain the dignity, individuality and privacy of all service users within a warm and caring atmosphere, and in doing so will be sensitive to the service user’s ever changing needs”. It was evident during this inspection that the above statement is reflective of current practices within the home. The manager stated that she believes the management and care staff team, work cohesively together and there is an ‘open’ and ‘transparent’ culture within the home. Staff spoken with, were very complimentary about the manager and deputy manager. Staff stated that they had confidence in the manager to deal with issues and/or areas of concern raised effectively. All sections of the AQAA were completed and the document returned to us when requested. Information recorded was informative providing a reasonable level of information about the service. It is evident from this inspection that there are some positive outcomes for the people living at Avondale. These relate to there being an appropriate admission process in place for prospective residents, people being able to participate in a varied programme of activities, people receiving a varied diet to suit their needs, staff working at the home knowing the needs of individual people and providing care and support that is both respectful and dignified. However, further development is required to ensure that care planning/risk assessing processes and procedures are improved, current medication practices and procedures are rectified and ensuring that staffing levels are maintained for the numbers and needs of residents’ so as to ensure their safety and wellbeing. We were advised by the manager, that a quality assurance system is to be shortly implemented, so as to seek the views of the people who live at Avondale, their representatives, care staff and professionals who visit the home. The purpose of this is for people to comment on the quality of the services provided at Avondale and for the management team of the home to address issues raised. On inspection of the staff supervision matrix, this showed that no members of staff have received formal supervision in line with National Minimum Standards recommendations. The manager stated that she was aware of the shortfalls, however this was due to her having a period of absence from the home as a result of ill-health. A health and safety policy was observed within the home. The majority of staff who work at the care home had received health and safety training. Avondale Rest Home DS0000071829.V374666.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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 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 2 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X X 2 X 3 Avondale Rest Home DS0000071829.V374666.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? N/A 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 13 Requirement Risk assessments must be devised for all areas of assessed risk so that risks to residents can be minimised. Records must be explicit detailing the specific risk, how this impacts on the person and steps taken to reduce the risk. This will ensure that risk areas are identified and staff, are aware of the associated risks to individuals’ health and wellbeing. Each person must have a plan of care, which clearly identifies their care needs and how these will be met by staff. This will ensure that staff have the most up to date information and can provide appropriate care to meet their needs. Where people are at risk of losing weight, maintain appropriate nutritional records, including weight gain or loss and appropriate action taken. So as to ensure peoples’ safety and wellbeing. Avondale Rest Home DS0000071829.V374666.R01.S.doc Version 5.2 Page 26 Timescale for action 21/05/09 2. OP7 15 21/05/09 3. OP8 17 21/05/09 4. OP9 13 Ensure that the medication trolley is not left unattended and medication easily accessible to residents and others. This will ensure unnecessary risks to residents’ health and wellbeing is prevented. Ensure that when medication is not administered to residents, records clearly record this, the rationale why they are not and any action taken to address the above. This is to ensure a clear audit trail and to ensure people’s health and welfare. Where a variable dose of medication is prescribed, ensure that the specific dose administered is recorded. This will ensure unnecessary risks to residents’ health and wellbeing is prevented. All staff who administer medication to residents, are assessed regularly as to their continued competence to carry out the task safely and in accordance with regulatory requirements. So as to ensure unnecessary risks to residents’ health and wellbeing is prevented. Ensure there are sufficient staff on duty at all times. So as to ensure the needs of the people in the home are met according to their specific needs and dependency levels. Ensure that robust recruitment procedures are adopted at all times. DS0000071829.V374666.R01.S.doc 04/05/09 4. OP9 13 04/05/09 5. OP9 13 04/05/09 6. OP9 18 21/05/09 7. OP27 18 04/05/09 8. OP29 19 04/05/09 Avondale Rest Home Version 5.2 Page 27 9. OP36 18 This will ensure that residents and others feel assured that they are safeguarded by the home’s procedures. Ensure that staff, receive regular 01/06/09 supervision. So that staff feel supported and residents know that staff are appropriately managed. 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 OP9 Good Practice Recommendations Record the temperature of where medication is stored each day, so as to ensure this does not deteriorate and lose its effectiveness. Avondale Rest Home DS0000071829.V374666.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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. 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