CARE HOMES FOR OLDER PEOPLE
Avondene 171 Stanpit Mudeford Christchurch Dorset BH23 3LY Lead Inspector
Jo Palmer Unannounced Inspection 10:00 30 January 2006
th 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 DS0000026761.V270614.R01.S.doc Version 5.0 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. DS0000026761.V270614.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Avondene Address 171 Stanpit Mudeford Christchurch Dorset BH23 3LY 01202 483991 01202 483991 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) Christchurch Housing Society Mavis Groombridge Care Home 11 Category(ies) of Old age, not falling within any other category registration, with number (11) of places DS0000026761.V270614.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 9th September 2005 Brief Description of the Service: Avondene is registered with the Commission to accommodate a maximum of 11 residents in the category OP(old age). Christchurch Housing Society, a local charity, own and manage several other registered services in the area as well as Avondene. The home is a detached property occupying a corner plot close to Mudeford Quay and the local amenities of Stanpit. Christchurch town centre is a short journey away. There is access via public transport. There is a bus route past the home. All 11 bedrooms in the home are single with over half having en-suite facilities. There is a lounge, sun lounge and dining room. There is a sun porch at the entrance to the home. There are bathrooms on the ground and first floor. DS0000026761.V270614.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection on 30th January 2006 lasted for three hours. Mavis Groombridge, registered manager was present and assisted throughout the inspection providing necessary information, access to records and introductions to residents. Mr Hickish, appointed by the Housing Society to be the responsible individual for Avondene was present for part of the inspection and available for discussion. This was a brief inspection the purpose of which was to review practices in relation to some of the National Minimum Standards. Not all standards were assessed and the reader is referred to the report of the last inspection dated 9th September 2005, which can be obtained either from the home or can be viewed on www.csci.org.uk The inspector spoke with eight residents, two members of staff, Mr Hickish and the manager, took a tour of the premises and examined relevant records. What the service does well:
Information is available to prospective service users detailing the care and services provided by the home, this information is presented in the form of a well-written Service User Guide which contains the home’s Statement of Purpose. Prior to agreeing to move to the home, residents are assessed in order that their needs can be identified and they can be assured the home is a suitable environment where those needs can be met. Contractual arrangements are entered into between the home and the resident detailing the terms and conditions of their stay. Following admission and where a resident’s needs have been assessed, a plan of care is usually drawn up to inform staff of the persons needs and how to meet them. Care plans provide basic detail regarding the person’s physical health, personal care needs and general welfare. Some attention is needed to ensure all residents have a planned programme of care on which they have been consulted. Where able, residents are encouraged to manage their own medication, where the home takes responsibility for this, good practices are adopted that are in accordance with Royal Pharmaceutical guidelines. Residents spoken with confirmed that staff treat them respectfully and with kindness, one resident commented that staff ‘can’t do enough for you’ and that they are ‘always ready to help’. DS0000026761.V270614.R01.S.doc Version 5.0 Page 6 Avondene provides a social and leisure environment that meets the expectations of residents with many being able to organise their own recreational pursuits. The complaints procedure is contained in the Service User Guide and Terms and Conditions of Residence document and gives residents assurance that their concerns, if any, will be listened to and managed effectively. Avondene provides a good standard of accommodation where residents are able to live quietly and privately although are able to enjoy each other’s company in the communal areas if they choose. Bathroom and toilet facilities are easily accessible and the home is clean and well maintained. Management systems at Avondene are well organised and the manager is supported by the registered providers (Christchurch Housing Society) in the home’s administration. A quality assurance programme is currently underway which, when completed, will ensure that Avondene continues to develop in accordance with recommended good practice and based on views of residents and relatives. 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. DS0000026761.V270614.R01.S.doc Version 5.0 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 DS0000026761.V270614.R01.S.doc Version 5.0 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 the following standard(s): 1, 2 & 3. Standard 6 in not applicable The home’s Service User Guide and Statement of Purpose provide residents and their relatives with sufficient information about the care and services at Avondene. Residents do not move to Avondene before having their needs assessed and being provided with assurance that Avondene is a suitable place for them to live. EVIDENCE: A Service User Guide which contains the home’s Statement of Purpose is available to residents at the home. Mavis Groombridge, manager confirmed that this document is available to residents prior to moving to the home in order that they can assess the services and facilities available before making a decision to move in. Prior to admission, residents needs are assessed to ensure both themselves and the home that Avondene is suitable to meeting their needs. A resident consultation form forms part of the pre-admission assessment where the resident or their representative can sign to confirm that they agree with the assessment of need.
DS0000026761.V270614.R01.S.doc Version 5.0 Page 9 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 & 10 Where care plans are available, they provide sufficient detail informing staff how to meet resident’s needs although not all residents can expect a planned, care programme. Access to health care professionals is facilitated by the home enabling resident’s health needs to be met. There are satisfactory arrangements for managing medication in the interests of residents. A kind and caring staff group treat residents respectfully. EVIDENCE: Two care files were examined, of these, one held a care plan that details the persons daily routine including any required care intervention from staff although basic information was available that was not based on any discernible assessment criteria. The second care file for a resident recently admitted to the home did not have any form of care plan, staff are therefore attending to this resident without clear instruction of the persons needs or how to meet them. Some notes were available relating to the resident needing ‘some assistance to get washed and dressed’ and ‘must only drink 1000ml of water daily’. Care plans must detail the assessed need and how it is to be met, it is also
DS0000026761.V270614.R01.S.doc Version 5.0 Page 10 advisable to identify the purpose of a particular care instruction in the care plan to inform staff of the reason a person has a particular need in order to aid staff understanding of the rationale behind certain care tasks. Part of the care files are entitled ‘risk review’, these had been completed monthly since admission and detailed how the person was settling in and any significant events. There were no risk assessments relating to risks of falling, skin vulnerability, nutrition, risks of accidental scalding (see also standard 25) or potential risks associated with any individual daily activity. Daily report records seen referring to care provided for each resident and any other significant events provided a detailed description of their lives in the home, records are well written, concise and address personal care, health and social care issues. Daily records and other information held on file provided evidence that residents are able to maintain contact with community health care professionals and hold appointments as required. Residents spoken with confirmed they were able to see their GPs at any time and that staff in the home quickly make arrangements when required. Medication systems were reviewed. The supplying chemist provides medicines to the home in 28-day blister packs that come with supporting documentation. Pre-printed records provided by the chemist with the medication allow for the recording of when the medication has been administered to each resident to be maintained. Some medicines, not suitable to go in blister packs including liquid medications and ‘as required’ medicines are supplied in correctly labelled boxes or bottles. A review of the blister packs and stocks of medicines demonstrated that correct systems are adopted and residents receive their medicines in the correct dose at the correct time. A few gaps in administration records were noted although not a significant number. Records of receipt and disposal of medication are held and appropriately signed. DS0000026761.V270614.R01.S.doc Version 5.0 Page 11 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 & 14 Residents are supported in making decisions about their daily social and leisure activities in the home as far as their health and general abilities allow. EVIDENCE: Daily reports examined demonstrated the extent to which the service user enjoys social and leisure activities. The social calendar for Avondene was not examined although it was apparent from speaking with residents that social care is provided in some organised group activities such as music and movement and occasional entertainers. Generally, residents are able to enjoy self determined activity and arrange their own social and leisure pursuits with their friends and families, those spoken with also confirmed that they are able to spend time in their rooms or the lounge areas and have books, magazines, music and television available. DS0000026761.V270614.R01.S.doc Version 5.0 Page 12 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 A written complaints procedure is available giving residents confidence that steps will be taken to deal with any complaint or concern they may have. EVIDENCE: The last inspection reported standard 18 as met. The complaints procedure is available in the Service User Guide and residents spoken with confirmed that they would know who to talk to if they had any concerns. No complaints have been received. DS0000026761.V270614.R01.S.doc Version 5.0 Page 13 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, 23, 24 & 25 Avondene provides a comfortable, environment for those living there and visiting. The home is clean and well maintained and there are sufficient facilities for residents in their private accommodation, communal lounge and dining room space, bathrooms and toilets. Resident’s safety is however compromised by poor fire safety measures and insufficient identification of risk factors posed by the environment. EVIDENCE: Standard 19 was not totally inspected although it was evident during a tour of the premises that fire doors are held open inappropriately, compromising the a safety of the residents, staff and premises. Avondene has a comfortable lounge, sun lounge and a dining room, which at the time of inspection were being used by several residents listening to music and enjoying each other’s company. There is a bathroom on each floor, both fitted with mechanical aids to assist residents getting in and out of the bath. There are sufficient toilets sited
DS0000026761.V270614.R01.S.doc Version 5.0 Page 14 around the home, additionally, six of the eleven single rooms have en-suite facilities. Avondene provides pleasant, homely surroundings where residents can live in comfort with their own belongings around them, residents spoken with confirmed that their rooms suited their needs. Residents spoken with confirmed that the home was maintained at a comfortable temperature, all areas visited were well lit and ventilated. Water temperatures were not measured. Radiators around the home in resident areas are not guarded, Mavis Groombridge confirmed that she is soon to complete risk assessments in respect of this to identify potential hazards to residents of accidental scalding. Guidance issued by the Health and safety Executive has been sent to the home to aid this process, it is however a requirement that risk assessments are carried out and that control measures are in place where risks are identified. DS0000026761.V270614.R01.S.doc Version 5.0 Page 15 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): 28 Avondene is working toward better staff training programmes to ensure all staff are equipped with the skills necessary to meet residents needs. EVIDENCE: Mavis Groombridge confirmed that twelve care staff are employed, of these two have attained NVQ level 2 in care, one has attained level 3 and three staff are currently working toward their NVQ level 2. Ms Groombridge confirmed that one member of staff has an up to date first aid certificate, all staff have attended training in food hygiene, infection control, safe handling of medication and health and safety; updates are planned for the coming months. Nine care staff have undertaken training in adult protection issues. Standards 27, 29 & 30 were assessed at the last inspection which reported these standards as met. DS0000026761.V270614.R01.S.doc Version 5.0 Page 16 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 The management arrangements of the home support good care practices for residents; the manager has a good grasp of the home’s administrative and management systems and is supported well by The Christchurch Housing Society. The manager is currently undertaking a quality assurance exercise that will ensure the home continues to be run in the best interests of residents. Systems are in place to ensure residents have representation for managing their financial affairs. EVIDENCE: Mavis Groombridge has attained NVQ level 4 in management and care and is currently studying toward the Registered Managers Award. Ms Groombridge demonstrated knowledge of management and administrative processes throughout the inspection and has an inherent respect and knowledge of the
DS0000026761.V270614.R01.S.doc Version 5.0 Page 17 individual residents in her care. Ms Groombridge is supported in her role by Christchurch Housing Society and Mr Hickish, the responsible individual. Staff and residents spoken with confirmed that the management arrangements of the home were good and they felt there was an open atmosphere where they were able to air their views and express opinions. A quality audit file was examined and noted to hold questionnaires that had been sent to, and returned from relatives of residents living at the home. Responses to questions were positive and encouraging. There were no available audits on other aspects of care or service provision and no development plan, Ms Groombridge confirmed that she would be working on this over the coming months and is reminded to send a copy of her development plan to address any issues of improvement to the Commission. Ms Groombridge confirmed that the home does not get involved in managing or assisting any resident with their personal financial affairs and that all residents either manage their own or have support and representation from next of kin, power of attorney or solicitor. DS0000026761.V270614.R01.S.doc Version 5.0 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 1 3 3 X 3 3 2 X STAFFING Standard No Score 27 X 28 3 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 X X 1 DS0000026761.V270614.R01.S.doc Version 5.0 Page 19 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 All service users must have an up to date care plan, available for staff reference detailing how their needs are to be met. Care plans must be based on comprehensive assessment and kept under review and must detail all aspects of each persons health and welfare. Fire doors must not be held open by unauthorised means. Where a resident wants their door held open, an appropriate door closure must be fitted to enable the door to remain open although close automatically in the event of a fire. All service users must have an assessment in relation to the risks of accidental scalding posed by unguarded pipe-work and radiators. In the absence of risk assessments, all pipe-work and radiators must be guarded or have guaranteed low surface temperatures. Timescale for action 1 OP7 15 30/04/06 2 OP19 23 30/04/06 3 OP38 13 30/04/06 DS0000026761.V270614.R01.S.doc Version 5.0 Page 20 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 OP25 Good Practice Recommendations It is recommended that radiators and exposed pipe-work are guarded. DS0000026761.V270614.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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