Inspection on 04/09/07 for Avonleigh Gardens

This inspection was carried out on 4th September 2007.

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

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Avonleigh Gardens Clyde Street Oldham Lancashire OL1 4HT Lead Inspector Mrs Fiona Bryan Unannounced Inspection 4th September 2007 09:40 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 Avonleigh Gardens DS0000069440.V348005.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. Avonleigh Gardens DS0000069440.V348005.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Avonleigh Gardens Address Clyde Street Oldham Lancashire OL1 4HT 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) 0161 627 5722 0161 633 2688 home.fxg@mha.org.uk Methodist Homes for the Aged Yvonne Marie Reilly-Cooper Care Home 40 Category(ies) of Dementia (3), Learning disability (1), Learning registration, with number disability over 65 years of age (4), Old age, not of places falling within any other category (28), Physical disability over 65 years of age (4) Avonleigh Gardens DS0000069440.V348005.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category 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: Dementia: Code DE (maximum number of places: 3); Learning disability over 65 years of age: Code LD(E) (maximum number of places: 4); Physical disability over 65 years of age: Code PD(E) (maximum number of places: 4); Learning disability: Code LD (maximum number of places: 1); Old age, not falling within any other category: Code OP (maximum number of places: 28). The maximum number of service users who can be accommodated is: 40. Not applicable. Date of last inspection Brief Description of the Service: Avonleigh Gardens is a purpose built care home owned by Methodist Homes for the Aged. It is located in the Watersheddings area of Oldham and is situated close to a main road, bus routes and local amenities. Accommodation is provided in 34 single bedrooms and three twin bedded rooms, all of which have en-suite toilet facilities. The home is arranged in four units (wings), each of which comprises bedrooms, lounge, dining and kitchen facilities for service users. The weekly fees range from £328 to £348, with additional charges for sundry items such as hairdressing services and newspapers. A service user guide is available on request. Avonleigh Gardens DS0000069440.V348005.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection, which included a site visit, took place on Tuesday, 4th September 2007. The home was not told beforehand of the inspection visit. All key inspection standards were assessed at the site visit and information was taken from various sources, which included talking with people who live at the home, visitors to the home, the manager and other members of the staff team, observing care practices and how staff related to the residents and considering information which we asked the manager to supply before the site visit was carried out. Before the inspection, comment cards were sent out to residents and relatives asking what they thought about the care at the home. Information from these has also been used in the report. Three people were looked at in detail, looking at their experience of the home from their admission to the present day. A partial tour of the building was conducted and a selection of staff and care records was examined, including medication records, employment and training records and staff duty rotas. This was the first inspection for the service, which has been classed as a new service as it has been bought by a new provider, Methodist Homes for the Aged. What the service does well: Avonleigh Gardens is a spacious home, separated into four wings, which provide plenty of choice for residents as to where and how to spend their day. Comments were unanimously positive about the standard of cleanliness and, on the day of the site visit, the home was very clean, tidy and fresh smelling. One resident said the laundry and cleaning services at the home were “smashing”! Staff were seen to treat residents as individuals and spoke to them in a warm and relaxed manner. This made the atmosphere within the home pleasant and calm. Residents seemed to like the staff and many were chatty and at ease with them. Avonleigh Gardens DS0000069440.V348005.R01.S.doc Version 5.2 Page 6 Comments included “I feel happy, secure and cared for at Avonleigh Gardens. I feel the staff know me well and care about me”, “all the staff will help you” and “I like living here”. A relative said that visitors were made to feel welcome and that the home was well organised. Another relative said “I have every confidence in Avonleigh Gardens staff and have always found them all to be kind and considerate to (my relative)”. The majority of people asked thought the food provided at the home was very good. Comments included “The food is very good – the girls in the kitchen are good – if you don’t like either choice you can ask for something different”, “I enjoy and look forward to meal times” and “(The home provides) good nourishing meals”. Residents said staff talked to them about their health care needs and were quick to contact their GP if they were not well. Staff had spent a lot of time writing new care plans, which were detailed and ensured that staff knew what care each resident needed. Residents were very satisfied with the arrangements made to provide social activities and events and a relative commented that the activities organiser was well motivated and enthusiastic. Residents’ meetings are held regularly so that people can put forward suggestions for activities, etc. 83 of care staff have a NVQ qualification and training in other topics was also extensive, meaning that staff have the skills and knowledge to look after people living at the home to a high standard. Staff, residents and relatives had a high regard for the manager saying that she was approachable and supportive. Staff meetings had been held regularly to support staff through the change of ownership and the new policies and procedures that were implemented. Residents felt that the change of ownership had had very little impact on them. What has improved since the last inspection? This was the first inspection for Avonleigh Gardens under its new owner. Avonleigh Gardens DS0000069440.V348005.R01.S.doc Version 5.2 Page 7 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. Avonleigh Gardens DS0000069440.V348005.R01.S.doc Version 5.2 Page 8 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 Avonleigh Gardens DS0000069440.V348005.R01.S.doc Version 5.2 Page 9 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 and 3. Standard 6 is not applicable. Quality in this outcome area is good. Detailed assessments are undertaken before people come into to the home so they can feel confident that their needs can be met. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: Since the last inspection, the home has changed ownership and a new statement of purpose and service user guide have been written. Detailed information gave an accurate picture of the services provided and the type of lifestyle prospective residents may expect. The format of the guide is user friendly and easy to read. Avonleigh Gardens DS0000069440.V348005.R01.S.doc Version 5.2 Page 10 Three people were case tracked. Assessments had been undertaken for all of them before they were admitted to the home. Residents are assigned key workers who are responsible for carrying on the assessment process once the resident comes into the home and adding extra information as residents’ abilities or needs change. It was evident from the records that residents had been involved in their assessments and they had been asked to sign their assessments to indicate that they had been discussed and agreed with them. Assessments were person-centred and focussed on people’s abilities, as well as determining what their care needs were. Avonleigh Gardens DS0000069440.V348005.R01.S.doc Version 5.2 Page 11 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 good. Staff work in partnership with other professionals to ensure that people’s health care needs are met. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: Methodist Homes for the Aged have introduced new care planning documentation and staff have been working hard to complete the records in line with the company’s policies and procedures. The company has provided training and support to staff to help them understand the new documentation and how it is to be completed, and systems have been put in place to ensure that the records are regularly reviewed and audited by the senior carers and the manager. Avonleigh Gardens DS0000069440.V348005.R01.S.doc Version 5.2 Page 12 The manager and staff were very positive about the new documentation and felt that when they were fully used to it, it would be a useful working tool to help them identify, plan for and evaluate people’s care needs. All the staff spoken to thought that the new documentation was an improvement on the records they had kept before and they are to be commended for the detail they have managed to include in the records in a short space of time. Three people were case tracked. All had care plans (which at Avonleigh Gardens are called support plans) that were person-centred and detailed. Risk assessments had been undertaken to assess risks relating to falls, moving and handling and pressure ulcers. The MUST tool was available to assess residents’ nutritional status but although people’s weight had been recorded and checked monthly, their BMI (body mass index) had not been calculated, so a score using the MUST tool was also not determined. Staff could start to use this tool to help them identify when they need to involve other health care professionals, such as the dietician. Support plans had been reviewed at least monthly but, in many cases, much more frequently, as they were updated as soon as any changes were noted in respect residents’ health, abilities or care needs. Records showed that residents had seen GP’s, opticians, podiatrists and district nurses. Residents said that they felt their health care needs were well met and there was evidence that health care needs had been discussed with them and their views obtained about what treatment they needed. Staff felt that the new records made it easier for them to retrieve relevant information when required by other health care professionals, for example, at reviews. During the site visit staff were observed, at all times, to be interacting with residents in a polite, professional but friendly manner and a relative commented that whenever they visited they noticed that staff were always kind and respectful to residents. Staff were seen encouraging residents to maintain their independence, for example, one resident was supported to walk a short distance but the staff member was on hand to help them into a wheelchair when they said they could not walk any further. A relative said that residents were “really well cared for” and went on to say that “the thing that strikes you most is that all the residents are treated as individuals”. Examination of a number of medicine administration records showed that medicines had generally been received into the home, administered and disposed of appropriately and stock levels were satisfactory. The manager said that the home would shortly be changing pharmacy supplier to Boots, in line with the new company’s policy and staff were to receive training in the new system. Avonleigh Gardens DS0000069440.V348005.R01.S.doc Version 5.2 Page 13 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 excellent. Staff are aware of the need to provide opportunities for social stimulation and interaction for people living at the home and meet these needs well. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: A full-time activities organiser is employed at the home who works five days a week, on a rotational basis, so sometimes she works at the weekends. A designated “activities” room is provided, which was spacious and well equipped with a variety of materials for arts and crafts, games and videos, etc. A range of activities is offered and residents are encouraged to put forward suggestions about the type of events they would like arranged. Avonleigh Gardens DS0000069440.V348005.R01.S.doc Version 5.2 Page 14 A programme of activities for the week was displayed on notice boards on both floors of the home. Activities included ball games, exercises and singalongs. The hairdresser visits the home every Monday and film nights are held on Wednesdays and Saturdays. On the day of the site visit a group of about 14 residents had congregated in the activities room and spent the morning joining in with exercises and ball games. Following the morning session the inspector chatted with the group and asked their opinions about how the home was run. All the residents said they felt there were plenty of activities and spoke about a recent cheese and wine evening they had enjoyed and the mobile shop which sold items such as toiletries, toothpaste, soap, drinks, sweets and hankies, etc. Residents said they did not tend to go out much but entertainers were invited into the home to sing. On the day of the site visit a singer came to the home in the afternoon and many residents attended and enjoyed the entertainment. A visitor said that they thought the activities offered by the home were very good and commented that the activities organiser was very well motivated and committed to her job. The notice boards also provided information about social events going on outside the home that the residents could get involved in if they wished, for example, there were details about an over 50’s friendship club and whist drives that took place on Saturday afternoons. Details of the advocacy service were also provided. Residents all said that their visitors were made welcome at the home and a relative who was visiting that day agreed with this. All residents’ rooms had door keys and there was evidence that every resident had been asked if they wished to retain their own key; some had chosen to do so. Residents’ rooms also had their own letterbox on the door and mail was delivered to individuals so they could read it in private. A visitor said that she found staff to be flexible and willing to adapt daily routines to support residents in doing what they wanted to, for example, she had taken her relative out one day and returned later than expected, missing the teatime; however staff had said it wasn’t a problem as they had saved some food and invited the resident to sit and eat with them while they had their supper break. A set menu operates over a three-week period. The manager said that the menus were reviewed every two months and changed to incorporate residents’ suggestions. Menus were reasonably varied and residents said that they liked the food provided by the home and that there was always a choice on offer. Avonleigh Gardens DS0000069440.V348005.R01.S.doc Version 5.2 Page 15 Although the menu only showed that a cooked breakfast was served on Sundays, residents said that it was actually available on alternate days. On the day of the site visit, lunch was served in the dining rooms on each of the wings. The choice on offer was either sausage and Yorkshire pudding or steamed fish in parsley sauce, with broccoli and cauliflower and mashed potato. The menu was displayed in each of the dining rooms and residents were asked to choose what they wanted as it was served. Staff also asked residents how much they wanted and offered to ask the kitchen staff for another alternative when one resident said he did not like either of the options being served. The atmosphere in all of the dining rooms was pleasant and calm. Residents and staff chatted to each other whilst the meal was served and some residents were helped discreetly. During the day jugs of juice were on hand where residents were sitting and staff were observed offering tea and coffee mid morning and mid afternoon. Residents said that they were offered toast or currant teacakes for supper and they particularly liked the currant teacakes. Avonleigh Gardens DS0000069440.V348005.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. People’s concerns are dealt with appropriately and residents are protected from abuse. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: The complaints policy is displayed on the notice boards on both floors of the home. Residents who were asked said that if they had a complaint, they would speak with the manager and all said that they were confident any concerns would be dealt with properly. Several residents said that they had not had any cause to make a complaint since they had been living at the home. A record of complaints received by the home had been maintained. This showed that the one complaint received this year had been responded to appropriately. The manager did say that she sometimes dealt with minor complaints immediately and, as they were resolved straight away, these were not recorded. The purpose of keeping a complaints record was discussed and the usefulness of using it as part of the home’s auditing procedures. Avonleigh Gardens DS0000069440.V348005.R01.S.doc Version 5.2 Page 17 The manager plans to provide a suggestions box to enable residents, relatives and staff to put their suggestions forward. Staff who were spoken to were aware of the procedures for safeguarding adults and said that if they were not satisfied with how any allegations were investigated or dealt with internally, they would inform social services. Avonleigh Gardens DS0000069440.V348005.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. The physical design and layout of the home enables residents to live in a safe, well-maintained and comfortable environment. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: The home is divided into four wings, which accommodate approximately ten residents each. Lounges, dining rooms, communal bathrooms with assisted baths and satellite kitchens are provided on each wing. Avonleigh Gardens DS0000069440.V348005.R01.S.doc Version 5.2 Page 19 A partial tour of the home found that the home was very clean, tidy and fresh smelling. Residents said they were satisfied with the standard of cleanliness and the laundry facilities in the home. One resident said the laundry and cleaning were “smashing”. Residents’ rooms were homely and inviting. Residents liked their rooms and said they were encouraged to bring personal items of their own into the home. Although the home does provide specialist baths, the deputy manager said that most residents preferred to take showers, as all the rooms had en-suite showers, which were easy for them to use. Lounges on each wing were bright, airy and comfortable. decorated differently and had its own ambience. Each lounge was Since Methodist Homes for the Aged took over the home, a maintenance person has been employed and the manager said this has created a big improvement in ensuring that minor maintenance jobs are carried out promptly. Over the last year, new carpets have been provided along the downstairs hallways and in all of the lounges on the ground floor. Double glazed windows had been replaced where necessary and the paving flagstones outside the front door have been re-laid. The garden was neat and tidy, safe and private but only a few chairs and a table were provided. The deputy manager said this was because there was nowhere to store garden furniture so the furniture they had was ruined in the bad weather. The manager applied for and has been given a grant from Oldham Local Authority and intends to use it to improve the garden; there are plans to provide awning to shelter residents from the sun and to create a sensory garden. Avonleigh Gardens DS0000069440.V348005.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 good. Staff are trained, skilled and in sufficient numbers to meet the needs of the residents. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: Staff said that, in general, they felt there were enough staff on duty to meet the needs of the residents. During the day staff rotas showed that there was usually one senior carer on duty plus four carers to look after 28 residents. In addition, the activities organiser works five days per week and is able to spend time talking with residents and meeting their social care needs, whilst carers deal with residents who require more personal care. The activities organiser is also on hand at lunchtime to help staff serve meals and feed residents that need help. Several residents did say that they felt there were not always enough staff as sometimes they had to wait when they needed help. Avonleigh Gardens DS0000069440.V348005.R01.S.doc Version 5.2 Page 21 The manager said that she had been asked by Methodist Homes for the Aged to submit a report detailing the current staffing levels and her opinion about what the optimum staffing levels should be in relation to the dependency of the residents. The manager felt that the company was willing to listen to her views and there was room for some flexibility in deciding staffing levels, which she would like to increase slightly at the busiest times of day. Staff personnel files were looked at and showed that staff had been recruited following thorough vetting procedures. Files contained all the information and documents required to assess the suitability of staff to work at the home. Residents said they felt confident in the staff’s ability to meet their needs and said they seemed knowledgeable and well trained. Training records showed that staff had received training in a range of topics, including management of medicines, stroke awareness, how to develop life stories and a foundation course in dementia care. A lot of the training is delivered by external trainers; the manager said that training is accessed through the Oldham Partnership and an external training organisation that the company widely use across all their homes. Staff have also now got access to e-training via the use of an e-box and packages of training covering the Common Induction Standards, health and safety and food hygiene. Of 31 permanent care staff, 26 staff have NVQ levels 2, 3 or 4. In addition, three domestic staff are doing NVQ level 2 in Housekeeping and two senior carers already possessing NVQ level 2 are undertaking their NVQ level 3. The deputy manager has NVQ levels 3 and 4 in Care and has undertaken the Registered Manager’s Award. It was reported that a programme of mandatory training is in place and is being rolled out to staff. All staff have completed fire training and manual handling. POVA training has been undertaken in the past and updates will be carried out over the next month. All senior carers have completed their first aid training along with some care staff, the maintenance worker and one of the domestic staff. Evidence was available that new staff received induction training in line with Skills for Care. Avonleigh Gardens DS0000069440.V348005.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, 35 and 38 Quality in this outcome area is good. The management of the home is effective, promoting an environment in which residents and staff may air their views and influence the care provided. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: The manager has NVQ level 4 in Health and Social Care, and NVQ level 4 in Management and completed the Registered Manager’s Award earlier this year. All staff, residents and visitors spoken to on the day of the site visit and those who returned comments cards said that the manager was approachable and Avonleigh Gardens DS0000069440.V348005.R01.S.doc Version 5.2 Page 23 supportive. One visitor said the manager was “very helpful and approachable – always welcoming”. Clear lines of management responsibility are in place. Staff said that the company’s services manager visited the home regularly. Senior carers received supervision from the manager and, in turn, held supervision sessions themselves with the more junior carers. Records showed that many staff meetings had been held with all grades of staff over the past few months in order to keep them fully informed about the changes that had occurred as a result of the new provider acquiring the home. Residents’ meetings are held regularly and are chaired by relatives so that they are impartial and to ensure that residents feel comfortable in expressing their views and suggestions. Residents said they felt their views were listened to. However, from the minutes of the meetings it was not really clear if any suggestions that were made had been acted upon and it was suggested to the manager that at each meeting the minutes of the previous meeting could be briefly discussed and the residents updated on what, if any, action had been taken as a result of their suggestions. It was reported that Methodist Homes for the Aged had recently distributed a residents’ survey to ascertain their views about how the home was being run. The manager had not received a report back from the head office about the findings at the time of the site visit. It is part of Methodist Homes for the Aged policy that audits are carried out by the home manager. Audits cover a range of topics, such as residents’ satisfaction regarding the arrangements to support privacy, dignity, independence and personal care and how the home is performing in relation to delivering staff training and reviewing policies. An audit undertaken in June 2007 showed that the majority of residents were very satisfied with most aspects of their care. Small issues that had arisen as a result of the audit were being addressed through staff meetings and supervision. The majority of residents are helped by their families to manage their money. Some relatives leave small sums of money as a “float” for residents to use for sundry items. It was reported that ledger sheets were held for these residents and records kept of all transactions but these were not examined at this site visit. Staff said there was enough equipment within the home to enable them to carry out their jobs safely and staff were seen to be working using safe working practices. Avonleigh Gardens DS0000069440.V348005.R01.S.doc Version 5.2 Page 24 Risk assessments had been carried out in relation to the environment and the maintenance person undertakes water, emergency lights and fire alarm checks, and other internal issues on a weekly or monthly check. Three fire drills had been held this year, at different times of the day and including at night. Avonleigh Gardens DS0000069440.V348005.R01.S.doc Version 5.2 Page 25 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 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 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 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Avonleigh Gardens DS0000069440.V348005.R01.S.doc Version 5.2 Page 26 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. 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 Avonleigh Gardens DS0000069440.V348005.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Manchester Local Office 11th Floor, West Point 501 Chester Road Old Trafford Manchester M16 9HU 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 Avonleigh Gardens DS0000069440.V348005.R01.S.doc Version 5.2 Page 28 - 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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