Inspection on 09/09/05 for Avondene

This inspection was carried out on 9th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Avondene 06/09/07

Avondene 17/07/06

Avondene 30/01/06

Avondene 15/11/04

Avondene 20/05/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Avondene 171 Stanpit Mudeford Christchurch BH23 3LY Lead Inspector Tracey Cockburn Unannounced 9 September 2005 10:35 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Avondene D55 S26761 Avondene V233535 090905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Avondene Address 171 Stanpit, Mudeford, Christchurch, Dorset, BH23 3LY Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01202 483991 01202 483991 Christchurch Housing Society Mavis Groombridge PC Care Home only 11 Category(ies) of OP - 11 registration, with number of places Avondene D55 S26761 Avondene V233535 090905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15 November 2004 Brief Description of the Service: Avondene is registered with the Commission to acommodate a maximum of 11 residents in the category OP(old age). Chistchurch 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 bedroom in the home are single with over half having ensuite 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. Avondene D55 S26761 Avondene V233535 090905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place unannounced on Friday 9th September 2005 over 3.5 hours in the morning and afternoon. This inspection was part of the annual cycle of inspections undertaken by the Commission. During the course of the inspection 8 of the 11 residents were spoken as well as 2 members of staff, 1 relative and the registered manager. Care records were examined and other records and staff files. Comment cards were also collected at the home, 6 from relatives/visitors and 9 from residents. The registered manager was present throughout the inspection. A tour of the premises was also undertaken. What the service does well: What has improved since the last inspection? There were no requirements and recommendations at the conclusion of the inspection in November 2004. Avondene D55 S26761 Avondene V233535 090905 Stage 4.doc Version 1.40 Page 6 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. Avondene D55 S26761 Avondene V233535 090905 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Avondene D55 S26761 Avondene V233535 090905 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3, standard 6 is not assessed as the home is not registered to provide intermediate care. Care documentation completed by the home means that no one moves in without the home and the person knowing and being assured that their needs can be met. EVIDENCE: The care files for 3 residents who moved into the home since the last inspection, were examined. All 3 files contained a pre admission assessment. The information in the assessments covered personal care, social care and medical history. There was no evidence of when the assessments were completed. Each files seen also contained individual care plans, which were based on the information gathered in the assessment. Care plans have been developed with the times that residents prefer to receive there care and are broken down into morning afternoon and evening routines. Avondene D55 S26761 Avondene V233535 090905 Stage 4.doc Version 1.40 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 standard(s) 7,8,10 Individual plans of care mean that care staff have the information they need to provide the care that residents require in the way that they prefer. Residents health needs are identified by care staff and the appropriate health care professionals are involved ensuring that residents get the care they need. Residents are respected and their privacy upheld which means they feel well cared for. EVIDENCE: The care plans for 3 residents were seen, each plan contained the information that care staff would need to meet the individual care needs in the way that each person would prefer however some of the care plans lacked specific detail in the way someone would like to be supported in terms of bathing or moving. Care plans are reviewed monthly and changes to an individual’s care needs are noted and the care plan updated. The residents sign the reviews. Each care plan was held in a larger file call “Philosophy of care” the larger file contained risk assessments, medical appointments and outcomes, record of weight and personal details such as family contacts. Many of the residents in the home are independent and can manage their own care needs. At the time of the Avondene D55 S26761 Avondene V233535 090905 Stage 4.doc Version 1.40 Page 10 inspection there were no residents who were at risk of pressure sores. The extend instructor was in the home providing an exercise class for the residents. Residents said that they are registered with GP’s of their choice. There was evidence in individual files that residents have access to hearing and sight tests and other medical appointments when they need them. During the inspection residents said that they are treated with respect by staff. One resident said that sometimes staff could be “a bit abrupt” but that she had discussed her concern with the manager. Some residents have private telephone lines in their own room. There is a phone in the hall, which can be used by residents. Avondene D55 S26761 Avondene V233535 090905 Stage 4.doc Version 1.40 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 standard(s) 13,15 The home encourages residents to maintain contact with family and friends; this means they are able to be in contact with the people that matter to them in their lives. Resident’s receive an appealing diet, which is mindful of their nutritional needs and provided in familiar surroundings. EVIDENCE: Residents said that they are able to see people in private and this was demonstrated during the inspection when several residents had visitors and were able to see them in private. A relative said that she was very happy with the care and attention received by her relative. She said that the staff were very attentive and always willing to help. Residents said that they are able to see whom they wish and were also able to make it clear when they did not want to speak to someone. The manager said she does not impose any restrictions on when people can visit. The main meal in the home is the mid day meal, all residents spoken to said that the food was good one resident said that the food was “perfect”. The menu for lunches for the week included: chicken casserole, fish and chips, cottage pie and roast pork. A variety of supper meals include: sausage and beans, ham salad and sandwiches. Breakfast is prepared according to Avondene D55 S26761 Avondene V233535 090905 Stage 4.doc Version 1.40 Page 12 individual preferences and wishes and is taken in their own rooms. The cook bakes cakes for tea in the afternoon and drinks are available throughout the day. The larder is well stocked, as were the fridges and freezers. There was fresh fruit and vegetables. A board in the hall has the day’s menu on it. Most residents eat in the dining room one or two prefer to eat in their own rooms. Avondene D55 S26761 Avondene V233535 090905 Stage 4.doc Version 1.40 Page 13 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 standard(s) 16,18 The homes complaints policy should give residents and their relatives confidence that their complaints will be taken seriously and action taken. The home’s policies and procedures combined with training for staff should protect residents from abuse. EVIDENCE: There have been no complaints since the last inspection. All care staff receive adult protection training as part of their induction. Avondene D55 S26761 Avondene V233535 090905 Stage 4.doc Version 1.40 Page 14 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 standard(s) 19,26 The home is a safe and well-maintained environment, which ensures that residents protected. The home is clean and hygienic providing a pleasant environment for residents and a good impression to prospective residents. EVIDENCE: The home has a programme of routine maintenance, at the time of the inspection, rooms were well decorated and furniture was in a good state of repair. The grounds are tidy and safe and accessible for residents, there is a ramp at the entrance to the home. There is no CCTV in operation. Avondene is very homely. The laundry room is sited away form the kitchen and does not intrude on residents. The laundry floor has an impermeable finish. There is a hand-washing facility in the laundry room. The home is very clean and pleasant and hygienic. There was one bedroom where there was a smell of stale urine. The manager explained that the carpet had been cleaned the day before but everyone was conscious that the room still smelt and they would be investigating further. Avondene D55 S26761 Avondene V233535 090905 Stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29,30 The home provides sufficient staff to meet resident’s needs. Ensuring that there is the right number of staff with the skills needed to provide a stimulating and caring environment. Recruitment practices within the home ensure that residents are protected. The home has a good training programme encouraging care staff to be responsible for developing their skills and enabling them to be competent at their jobs. EVIDENCE: The home has a staff rota showing who is on duty and at what time. Normally there are 3 members of staff on duty in the morning and 2 in the afternoon. The registered manager is always on duty and this is demonstrated on the rota. One person responded on their comment card that there were not enough staff on duty. Three members of staff have been enrolled on the NVQ 2 with NVQ Initiatives. They have been enrolled for several weeks but the home has not yet received confirmation of when the staff will start. A senior member of staff within Christchurch Housing Society was exploring this delay. There have been 2 new staff appointments since the last inspection. These files were examined both had 2 written references and enhanced CRB checks Avondene D55 S26761 Avondene V233535 090905 Stage 4.doc Version 1.40 Page 16 including POVA first. Staff are given copies of the general social care council code of conduct. Both members of staff were given terms and conditions. Induction training is arranged within 6 weeks of commencing in the post. The manager has a training and development programme and keeps individual records of each member of staffs training needs and when qualification such as first aid need to be renewed. Avondene D55 S26761 Avondene V233535 090905 Stage 4.doc Version 1.40 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,38 The home is well managed by a person who is able to undertake her responsibilities fully, this benefits staff and residents. Polices and practices of the home promote the health, welfare and safety of the residents and staff. This means that the staff have the information and guidance they need to provide a good service to residents. EVIDENCE: The registered manager is currently in the process of completing her NVQ level 4 she expressed some concerns about the delays being caused by the assessor, specifically that she has had to re do certain pieces of work and has not been told if she has passed or failed weeks after the observed practice. This has caused her unnecessary anxiety. There are clear lines of accountability within the home and the manager feels supported by her line manager. Avondene D55 S26761 Avondene V233535 090905 Stage 4.doc Version 1.40 Page 18 There was evidence that the registered manager has ensured that all staff have received training in moving and handling, first aid, fire safety, food hygiene and infection control. There was a bottle of cleaning fluid in the bathroom on the first floor which had not been stored safely. All electrical equipment had been checked, there are window restrictors on the first floor windows, the premises are secure and kitchen and laundry equipment is maintained. All accidents and incidents are recorded and appropriately reported. Avondene D55 S26761 Avondene V233535 090905 Stage 4.doc Version 1.40 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x x x x x x 3 Avondene D55 S26761 Avondene V233535 090905 Stage 4.doc Version 1.40 Page 20 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 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. 1. Refer to Standard Good Practice Recommendations Avondene D55 S26761 Avondene V233535 090905 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection 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 © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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