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Inspection on 24/03/09 for Avonmead Nursing Home

Also see our care home review for Avonmead Nursing Home for more information

This inspection was carried out on 24th March 2009.

CSCI found this care home to be providing an Good 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Avonmead Nursing Home 11 Canal Way Devizes Wiltshire SN10 2UB     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Susie Stratton     Date: 2 6 0 3 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 38 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 38 Information about the care home Name of care home: Address: Avonmead Nursing Home 11 Canal Way Devizes Wiltshire SN10 2UB 01380729188 01380729299 avonmead@fshc.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Laudcare Ltd (a wholly owned subsidiary of Four Seasons Health Care Ltd) care home 45 Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 Over 65 45 0 4 old age, not falling within any other category physical disability terminally ill Additional conditions: 0 4 4 No more than 4 service users over 55 years of age who are in receipt of Intermediate Care are accommodated at any one time. No more than 4 service users with a terminal illness may be accommodated at any one time The minimum staffing levels set out in the Notice of Staffing issued by Wiltshire Health Authority and dated 28 May 1999 must be met at all times Date of last inspection Brief description of the care home Avonmead is a purpose built care home that provides nursing and residential care. The home has single and double en suite accommodation for up to forty-five persons, distributed over two floors and served by a passenger lift. The home has an enclosed garden and patio area. Shops and local facilities are a short driving distance from the Care Homes for Older People Page 4 of 38 Brief description of the care home home in the Wiltshire market town of Devizes. There is ample parking on site. The owner of the home is Laudcare Limited, a wholly owned subsidiary of Four Seasons Health Care Limited, a national provider of care. The manager of the home is Mrs Sharon Cottrell who has been in post since the home opened. A deputy manager supports Mrs Cottrell. Registered nurses and care assistants are on duty at all times. An activity person is employed. Adminsative, catering, cleaning, maintenance and laundry staff are also employed. The current fees range between 450 pounds to 800 pounds per week but do not include chiropody, hairdressing, newspapers or transport costs. Care Homes for Older People Page 5 of 38 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: As part of the inspection, 40 questionnaires were sent out and 25 were returned. Comments made by people in the questionnaires and to us during the inspection process have been included when drawing up the report. As part of this inspection, the homes file was reviewed and information provided since the previous inspection considered. We also received an Annual Quality Assurance Assessment from the home. This was their own assessment of how they are performing. It also gave us information about what has happened during the last year. We looked at the quality assurance assessment, the surveys and reviewed all the other information that we have received about the home since the last inspection. This helped us to decide what we should focus on during the visit to the home. Care Homes for Older People Page 6 of 38 As Avonmead is a larger registration, the site visits took place over two days. The first site visit was conducted by an inspector who was accompanied by an infection control nurse from Swindon Primary Care Trust, who was being inducted into their role and by a person who is regarded as an expert by experience, who was identified for us by Age Concern. These people are referred to as we throughout the report, as the report is made on behalf of the Commission for Social Care Inspection (CSCI). The first site visit was on Tuesday 24th March 2009, between 9:20am and 4:20pm. The second site visit was on Thursday 26th March 2009 between 9:35am and 12:10pm. The first visit was unannounced. Mrs Cottrell, the manager was on duty for the first day and the operations manager also visited the home during the visit. Mrs Cottrell, the registered manager, the deputy manager and the operations director were available for the feedback at the end of the site visits. During the site visits, the inspector met with eight residents, two visitors and observed care for eight residents for whom communication was difficult. We toured all of the home and observed care provided at different times of day. We reviewed care provision and documentation in detail for four residents and reviewed certain aspects of care and documentation for a further four residents, across all parts of the home. As well as meeting with residents, we met with three registered nurses, five carers, two domestics, a laundress, the administrator and the chef. We observed a lunchtime meal and an activities session. We reviewed systems for storage of medicines and observed two medicines administration rounds. A range of records were reviewed, including staff training records, staff employment records, complaints records, maintenance records and the invoicing systems for additional services, such as hairdressing and chiropody. What the care home does well: What has improved since the last inspection? What they could do better: The home needs to further develop systems in care provision and planning, to ensure that all matters relevant to individual residents are documented. This is particularly in Care Homes for Older People Page 8 of 38 relation to prevention of risk pressure damage, including a consistent approach to care planning and documenting of care given to residents to prevent risk. Attention is also needed when residents are prescribed Oxygen or drugs via a nebuliser, to ensure that the equipment used is clean and changed on a regular basis. The home needs to review the quality of its systems for communicating relevant matters about meeting residents nursing and care needs, to ensure that all staff have the information that they need. Some improvements are needed in the storage of drugs being sent for disposal to ensure safety for all involved. Documents for medicines administration of medicines always need to be completed correctly to prevent risk of medication error. Where residents are prescribed drugs on an as required basis or where activities of daily living can be affected by medication, care plans need to be drawn up to ensure consistency and assist in evaluation. Staff working in the home must always comply with the providers policies and procedures when handling used linen, to prevent risk of cross infection. Storage rooms need to have clutter removed, so that the hand wash basin can be reached and sterile equipment not be damaged. All Oxygen cylinders need to be secured to prevent risk to people. Matters relating to prevention of spread of infection, such as provision of glove dispensers in toilets, naming of all jars of topical cream and commode chairs could be further developed. Staff files need to include full proof of identity. Systems are needed to show that staff are supervised until full police checks are returned and copies of relevant documents relating to police checks be on file in the home as well as the providers human resources department. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 9 of 38 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 38 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective residents will benefit from a full assessment, so that they can be assured that the home can meet their needs. Evidence: Avonmead has an established system for assessing the needs of prospective residents. The manager reported that she or her delegate always go out to meet a prospective resident prior to admission, to assess their needs and discuss the admission process. She also reported that she actively encourages people to both look over Avonmead and other homes in the area before reaching a decision on admission. In their annual quality assessment the home reported that they felt they had improved assessments people and had further developed their relationship with local social services. We met with some people who had been recently admitted to the home, including a person who had been admitted for respite care. Many of the people we met with Care Homes for Older People Page 11 of 38 Evidence: reported that they could not remember much about the admission process, as they had been unwell at the time. One person did report that they remembered that someone had come to see them in their own home. Another person commented in their questionnaire that they had been in hospital, overcoming an operation before their admission and so could not remember much about moving in. We reviewed admissions documentation. The home uses the providers standard assessment document. This document enables an assessment of a range of dependency needs before admission. Where relevant, the assessor also includes details of a persons specific needs in certain areas. We saw examples of an individuals dietary preferences and how they used their spectacles. The benefits of this assessment is that it can then be used as a base-line from which further assessments can be made, so that peoples improvements or increasing needs over time can be clearly identified. Assessments seen reflected what we observed. One registered nurse we met with was very aware of the individual needs of the person admitted for respite care and what the proposals were for meeting the persons future care needs. The chef reported that he makes a point of going to meet all newly admitted residents in person, to identify their preferences for meals and other factors relating to their dietary needs. Care Homes for Older People Page 12 of 38 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents health and personal care needs will largely be met, however any risks would be further reduced when improvements are made in communication systems for staff, prevention of risk of pressure damage and certain aspects of practice relating to medicines administration. Evidence: People commented to us about how the home met their needs. Of the people who responded in questionnaires, eleven people reported that they always and three that they usually received the care and support that they needed. One person reported that all residents are treated with respect and care practices are adhered to and another that the home gives comprehensive nursing care. One person commented to us my foots getting better and a relative reported that the care received was very nice thank you. Another person commented that one of the homes strengths was to meet the residents needs, comprehensive nursing care. In their annual quality assessment, the provider reported they had improved their documentation and that new equipment had helped in improved care provision. The assessment gave a picture Care Homes for Older People Page 13 of 38 Evidence: of a highly dependant resident population who had complex needs, as would be anticipated in a care home with nursing. Residents records were completed in detail, they included such significant factors as if a person preferred to spend their time in bed. This was confirmed by a person we spoke to. Records showed that residents are asked if they prefer personal care to be performed by a carer of their own sex. During the inspection, we observed a resident was deeply asleep in a recliner chair, just before lunch. A carer approached them gently and waited until the person was fully awake, before telling them what was happening and then moving them so that they could enjoy their lunch. Avonmead has established systems for assessment of resident need, including assessment of risk. If a need or a risk is identified, a care plan is put in place to direct staff on how the persons need was to be met or risk reduced. The home are developing more person-centred care plans, which are written in the first person from the residents point of view. Residents had clear assessments in relation to manual handling needs. Care plans were then drawn up to direct staff on how the resident was to be moved. These were reviewed when a persons condition changed. These care plans were completed individually and clearly directed care. Staff had ready access to such information, as manual handling care plans were kept in residents rooms. The provider has procedures in place to monitor incidences of pressure ulceration and infection. It was noted as good practice that the home reported on minor pressure ulceration and people who were assessed as having vulnerable tissue viability as well as major pressure ulceration. No residents had any major pressure ulcers at the time of the inspection. All residents were assessed for risk of pressure ulceration and these assessments were regularly reviewed. While the home has systems for assessing and reporting on pressure damage risk, there was not a consistent approach in care planning to reduce this risk. All people who were assessed as being at risk of pressure damage did have care plans in place, however care plans needed improvement. Some care plans were clear and directed staff on all matters to reduce pressure ulceration but others did not. Three of the care plans reviewed did not state how often the resident needed their position changed. One of the care plans stated that the resident needed their position changing every four to five hours, this does not conform to local or the National Institute for Clinical Excellence guidelines. One persons care plan had the required setting for their air mattress left blank and one persons setting on their air mattress, observed in their room did not relate to their weight as documented in their records. All residents who were at risk of pressure ulceration had turn charts in place. This is to ensure that people have their positions moved in accordance with their individual Care Homes for Older People Page 14 of 38 Evidence: needs. We looked at turn charts for the day before the inspection. These also showed variance. Some people had their positions changed regularly, in accordance with their level of risk. However for other people, turn charts were not completed to show that they had had their positions changed. One person who was assessed as being at high risk of pressure damage had no records of changes of position between 12:30 and 22:00 the day before the inspection, for the same day, another person had no records of changes of position between 12:30 and 22:45. Unless staff document when they have changed a persons position or if they have not, why this is, management are not in a position to ensure that risk of pressure ulceration to people is reduced. Pressure ulcers tend to take a long time to heal, present a risk of cross infection and are very painful. Therefore the emphasis needs to be on prevention. Where a resident had a wound, there were clear records relating to management of the wound, with regular assessments of the wounds response to treatment. Records showed that regular contact was made with the tissue viability nurse about persons wounds. One member of staff we spoke to who had worked elsewhere commented favourably on the effective supports to the home by the tissue viability service. Residents who needed support with diet or fluid intake had clear care plans in place. One person had very clear details of their individual likes and dislikes for meals. Where a person needed their fluids thickened to enable them to swallow safely, there were care plans to detail how thick the person needed their fluids to be, which we observed staff kept to. People who needed supports with taking in fluids had fluid charts in place, which were fully completed. The amount of fluids people were able to take in on a daily basis was documented and this was then evaluated monthly, so that relevant professionals could be advised. Where dieticians had given specific advice, this was included in care plans and evaluations. One registered nurse commented on the supports given to the home by the local dietician and speech and language therapists. Residents who were diabetics had clear care plans in place to direct staff, including actions to be taken when the persons blood sugar levels were raised or lowered. Residents who had continence needs had an assessment performed and where need was identified, a care plan was put in place to support the person. Some care plans documented which types of continence pads were to be used for the person but others did not. A carer we spoke to who was placing continence pads in residents rooms reported that continence pads were provided individually according to residents individual needs. Where a resident needed to have an indwelling urinary catheter, for one person the clinical reason for their catheter was documented but it was not for another person. This is needed as urinary catheters can be associated with increased risks of infection, so they should only be used when they are in the best interests of the person. Care Homes for Older People Page 15 of 38 Evidence: Two residents had care needs in relation to breathing problems. One person was observed to be using Oxygen via a concentrator. They had a care plan about administration of Oxygen and cleaning their nose, but they did not have a care plan about cleaning the nasal cannulae, which delivered oxygen or the oxygen tubing. Another person had medication which they breathed in via a nebuliser. When we looked at the oxygen mask. It was not clean, this might be anticipated for a person with a complex chest condition. The chamber for their nebuliser was damp, several hours after administration of the medication. Staff we spoke were not aware of regimes for cleaning this equipment and there were no care plans to direct staff. People with chest care needs are at risk of re-infection and cross infection if their equipment is not clean, dry and changed regularly. Some of the residents had additional mental health care needs. Where this was the case, clear non-judgemental care plans were in place. We noted as good practice that one person who was documented as having agitated behaviours was managed by staff without the use of mood altering medications. We met with one person who was very confused in time and place but they were relaxed and cheerful, showing no signs of distress at any time during the inspection. Residents can keep their own GPs when they move into the home. The home maintains clear records of discussions with residents GPs. One person reported medical support is very good. Staff reported that they had a good working relationship with the local GPs. One registered nurse who had worked elsewhere described the local GPs as super and very supportive. One registered nurse did comment that as a wide range of GPs attended the home, it would assist if a list of residents and which GP attended to them, including GP contact numbers, could be provided at each nurses station. We received comments in questionnaires from staff about how they were informed about resident needs. There was a variance in reply from staff. Five staff said they were always, three usually, one sometimes and one never given up to date information about the needs of the people they cared for. One person reported not always given a detailed handover prior to starting a shift, especially if you have had a few days off and another I am an ancillary worker - we are treated differently to care staff. We asked staff about this during the inspection. One person reported that they found handover meetings gave them what they needed to know and that they felt listened to by the registered nurses. Another person reported that they did not have time to read care plans. One person reported that if they had been off duty for a bit that the handovers were a bit brief and that they did not always know what to do if a residents needs had changed. One cleaner reported that they were sometimes Care Homes for Older People Page 16 of 38 Evidence: informed if a resident had an infection but at other times see yellow bins in room and so know. One person reported that some night staff wanted to get away and so did not inform of all matters and not in enough detail. This was discussed with the managers who were asked to review the quality of handover meetings to ensure that all staff were given all the information they needed to ensure that they would meet residents individual needs. During the inspection, we observed two medicines rounds. Each was done safely and in accordance with guidelines. The registered nurse was observed to always secure the medicines trolley when she was away from the trolley with a resident. We noted as good practice that the registered nurses performing the round wore a red tabard which stated that they were not to be disturbed during the round. One person reported tablets are always available on time. We looked at systems for storage of medicines. All were safely stored and fully secured, including Controlled Drugs. We did observe that the clinical waste container for drugs for disposal was so full that the container lid could not be secured and the level of the drugs waste was well above the safe level designated on the container. The container was placed in an empty container, so it would have been possible to ensure safe practice in management of medicines for disposal. We also looked at medicines administration records. We observed that where instructions were completed by hand they were signed and countersigned. Limited life medicines were dated when opened. We observed for one person that sections in their medicines administration record for that month had been completed but that instead of starting a new record sheet, the medicines to be administered for the next month had been repeated by hand in spaces lower in the original page. This is regarded as a risk, as such practice means that dates are not clear and increases the risk of medication errors. Where residents were prescribed medication, there was a lack of consistency in documentation in residents records. For one person on antibiotics and another person on ear wax loosening medication, there were clear records in their care plan. Whilst one person had clear directions in their care plans on when certain medications prescribed as directed were to be given, another two peoples care plans where they were prescribed medications as directed made no references to this in their records. Where people are prescribed medication as directed a clear care plan is need to ensure that all such drugs are administered by registered nurses in a consistent manner, in accordance with the persons needs. Where residents were regularly prescribed medication which can affect their daily lives such as aperients, mood altering drugs or painkillers, some people had reference to these prescriptions in their Care Homes for Older People Page 17 of 38 Evidence: records, but others did not. This is needed so that the effectiveness of such treatments can be regularly evaluated. Care Homes for Older People Page 18 of 38 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People will have their social care needs met and be able to exercise individual choice. Meal times are regarded as a key area of service provision. Evidence: The home have recruited a new activities person since the last inspection. This person is supported by staff and a volunteer. Of the 14 people who responded to this section of the questionnaire, eight reported that there were always, four usually and two sometimes activities arranged by the home that they could take part in. The manager reported that much of the current emphasis in activities was to develop strong links with the local community. For example people can go out of the home to go to the weekly market in Devizes, people have gone to the local pub, just down the canal and when they were re-planting the garden, residents and the activities person went to the garden centre close-by to purchase plants. The expert by experience commented I checked the communal lounge and found it welcoming with a lovely view over the garden. There was a large television in the room but I am pleased to say that it was not on, the quiet room was a delightfully comfortable room with lovely furniture and tempted me to sit and enjoy the atmosphere for a time. Care Homes for Older People Page 19 of 38 Evidence: A range of activities take place in the home. On the second day of the inspection a coffee morning was taking place, it was well attended by residents and visitors with a bustling, cheerful atmosphere. One resident commented to us I do Bingo. It was reported that they had had a local butcher in recently for sausage day. There were photographs of a range of different activities were displayed. On the first day of the inspection, a carer was performing individual manicures on residents during the afternoon. Activities were supported by individual care plans, these directed people on what residents wished to do and how this was to be achieved. Records of activities participated in also documented the benefit to the resident. The expert by experience commented most of the residents very much appreciated the Friday Afternoon Party Time in the main lounge and enjoyed the getting together rather than just watching television. It appeared that socialising and speaking to visitors was an important part of keeping residents happy and content and they wished that they could do more. The visitors book showed that visitors come into the home very regularly. Visitors spoken with reported that they felt able to come and go as they wished. The operations manager reported that, following comments by visitors, she was working on systems to make the home more easily accessible outside normal working hours and at weekends. One person reported that they regarded communication with relatives as one of the strengths of the service. The expert by experience commented I spoke to a number of residents they nearly all said that they missed their own homes and families and those who received visits said how much they were appreciated and looked forward to them especially on such special days as Mothering Sunday. Residents reported that they were able to decide how to spend their days. One person reported I use a hoist but I can get up and go to bed when I want, another If I fancied a day in bed, I can do so and another frail person reported that they sit out sometimes when I want. One person said to us If I say I dont feel to special, they leave you alone and that they appreciated this as they were not made to get up when they did not want to. One resident reported to us that they went to the lounge in the late morning, this was observed to take place in practice. One person reported that one of the strengths of the service was to give residents equal opportunities. All are treated with respect. The home has employed a new chef since the last inspection. This person is keen to improve and develop the meals service to the home and has made a range of improvements in the catering department. One person reported we have a new chef since your last inspection and the catering has improved 100 in choice, presentation and quality. The service users are aware of the improvement. The chef has revised the menus, ensuring that the principals of healthy eating are up-held. He now goes out and meets residents, aiming to meet then once or twice a week to receive their Care Homes for Older People Page 20 of 38 Evidence: comments on meals provision. In discussion, he showed a detailed individual knowledge of residents likes and preferences. The chef also dishes up the meals from the meals trolley in the first floor dining room. He reported that he cooks nearly all meals from raw ingredients, including soups, gravies and sauces. People commented on the meals. One person reported in their questionnaire the chef is very helpful and carers will help if there is any difficulty at meal times. One person commented basically good - you do get a choice, another very good, you get quite a lot and another I have what I want when I want it. One person commented that if they wanted something different instead of the main meal, for example scrambled eggs, the kitchen would do it for them. The expert by experience commented I asked all the residents to whom I spoke if they enjoyed the food provided and with the exception of one person that they did. The one complaint was so minor as to be of no significance. We observed that the chef plated up meals according to what the person wanted, using smaller plates for people with smaller appetites. He also ensured that meals were attractively presented, including liquidised meals. We observed that carers were available to support residents at mealtimes. One carer reported that lunch goes on for a long time because people needed support and they did not want to rush them. We observed that carers sat with residents who needed support to eat, encouraging them and observing that they were able to swallow safely. Where residents needed aids to assist them in eating, these were provided. Care Homes for Older People Page 21 of 38 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People will be safeguarded by the homes polices and have their complaints and concerns listened to. Evidence: Avonmead has a complaints procedure, which is available to people in the service users guide and which is displayed in the main entrance area. Of the fifteen people who responded to this section of the questionnaire, eleven people reported that they knew how to make a complaint. One person commented that they were always very happy. One person reported to us that I see the manager and deputy if they had a complaint. One person reported oh yes theyre approachable about the managers of the home. We have received one complaint about the home since the last inspection. This was passed back to the home for investigation and action. In their annual quality assessment, the home reported that they had received 12 complaints in the past 12 months. A review of complaints records showed as good practice that the manager takes action to investigate apparently small concerns as well as complaints. She explained to us that she wanted to ensure that all matters of concern to a resident were investigated and acted upon if relevant. We observed that one matter which had been brought up with us in questionnaires had also been brought up by another person as a complaint and discussed the action plan developed by the operations manager to ensure that the issues would be addressed. Care Homes for Older People Page 22 of 38 Evidence: The manager has experience of working within local safeguarding procedures. During the inspection, we discussed safeguarding with a range of people, including domestic and laundry staff as well as care assistants, all were aware of their responsibilities for alerting matters to protect vulnerable elderly people. The administrator showed a clear knowledge of this area and was able to give us an example of actions she had taken to ensure that a person was safeguarded. We looked at records and all staff have been trained in the area during the last year. No safeguarding referrals have been made about this home since the last inspection. Care Homes for Older People Page 23 of 38 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents will generally be supported by an environment which meets their needs, however some areas relating to prevention of spread of infection would benefit from improvement. Evidence: The providers have put much effort into improving the home environment since the last inspection. All parts of the home appeared to be well maintained. All sitting rooms have been improved, with redecoration and new furniture. A wide range of equipment has been provided, including variable height beds and chairs, particularly chairs for people with complex seating needs. We noted that the garden area has been made much more attractive, with a full up-grade and re-planting. People commented on the home to us. One person reported I am lucky to have this room and another that the home was very comfortable, very clean. Some of the residents had brought their own items into their rooms, giving them a homely atmosphere. The expert by experience reported there were no unpleasant smells in the home and it had a friendly atmosphere although slightly untidy in places. They also commented rooms were easily accessible as well as being bright and fresh smelling. They were warm and comfortably furnished and many had pleasant garden views. Care Homes for Older People Page 24 of 38 Evidence: Equipment is provided for people with a disability, including different types of baths and showers. Where people are assessed as needing air mattresses, air cushions are also provided on their chairs. The types of beds provided can lower close to the floor, so that the use of safety rails is reduced as much as possible. The expert by experience reported I noted that the hallways were well carpeted and there were handrails situated on both sides of the walls, many patients were sitting in comfortable chairs and those who were in bed were properly supported with bolsters. People commented on cleanliness. One person described Avonmead as A very good fresh and clean home and another Avonmead provides a clean and homely environment. One carer commented weve plenty of gloves and aprons. All parts of the home inspected were clean, including difficult to reach areas such as the backs of bath hoists and undersides of toilet rails. We met with a domestic who was able to describe how they safely used different mops for different areas and when they changed water and chemicals in the bucket to ensure good infection control practice. She reported that she had good supplies of equipment and cleaning chemicals. The chef described in detail the cleaning of the kitchen that he and his team perform. We met with the laundress. All of the laundry was clean and dust-free. The laundress reported that staff nearly always complied with infection control procedure when handling infected or potentially infected laundry. On the occasions that staff did not, she felt able to report this so that actions were taken to address the risk. We observed how staff handled laundry. On one occasion, we observed a carer bringing bed linen out of a residents room. They were not wearing an apron but were holding used linen to their unprotected uniform. They were wearing gloves. This is contrary to the homes policy that aprons must be used when handling laundry and that laundry containers must be brought to the room, to reduce risks of cross infection. We observed in toilets, including en-suites that boxes of disposable gloves were left on toilet cistern lids. This is not regarded as good practice, as in the event of an infection, gloves placed in such areas could become contaminated. It is advisable that boxes of disposable gloves are put in dispensers on the wall. We observed in peoples en-suites that while some peoples topical creams were labelled with their name, not all were. Unless jars of topical applications are named, there is a risk that creams can be used communally, which is a risk to cross infection. The operations manager confirmed that staff have been instructed to change gloves before applying creams to reduce risks of cross infection. During the inspection, we observed that the first floor sluice room was very cluttered with commode chairs and that it was not possible to reach the hand wash basin with Care Homes for Older People Page 25 of 38 Evidence: ease. The hand wash basin was dry, so it was unlikely that it had been used that morning, due to this. As hand washing is regarded as the single most important factor in preventing cross infection, staff need to be always able to access the hand wash basin and to be able to use it after they have been handing items in the sluice room. As the home have several commode chairs, it would be preferable for commode chairs to be labelled with the residents name and used only for them. Many of the residents needed hoisting using slings. It was reported that all residents with known infection had their own slings and that more were in the process of being purchased, so that each person would in the future be allocated their own sling, to reduce risks of cross infection. The downstairs store room for clean and sterile items was also cluttered. During the inspection, we observed that it had not been able, due to the clutter, to store all items tidily. One item had had its sterile cover perforated and so would not to be able to be used, due to how it had been stored. This room also therefore needs to be tidied up, to ensure correct infection control practice. Care Homes for Older People Page 26 of 38 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples needs will be met by sufficient numbers of staff, who have been safely recruited and are trained in their roles. Evidence: At the last inspection, this outcome area was judged to be adequate. Comments received at that time indicated that there were times when staff availability impacted on residents receiving prompt attention and the home was asked to review care staff levels to ensure that they are adequate to meet peoples needs. In their annual quality assurance assessment, the provider reported that the ratio of staff to resident had been improved. This was found to be the case at the inspection. The expert by experience commented I noted that the staff worked very quietly and all were very polite and appeared to be clean, smart and tidy in their uniforms. People who commented on staffing in questionnaires, eleven people reporting that they always and three usually received the care and support that they needed. One person additionally commented that the home were very good in this area. Staff commented that the main issues with staffing of the home related to if staff were off sick at short notice as finding people to cover in such circumstances was complex. Some residents felt that there could be a slow response to call bells. During the inspection, we tried residents call bells on three occasions and on each occasion staff Care Homes for Older People Page 27 of 38 Evidence: attended to the resident in under two minutes. One person commented to us, yeah I ring my bell for help and they come. The home has safe systems for the recruitment of staff. This was confirmed by staff in questionnaires. The manager reported that they were currently having a good response for carers and ancillary staff when they advertised. We reviewed staff employment records and we observed that all staff have a full employment history, police checks, two references and complete a health status questionnaire before employment. Most staff had proof of identity, including a photograph, but not all. Other photographs were photocopies of passport or driving licence photographs and so were not clear. The home are required to hold a photograph of each member of staff to provide full proof of identity. The provider has standard systems for risk assessing any member of staff who has a criminal record. Such issues are dealt with centrally by the providers human resources department. In some, but not all cases, a copy of the human resources assessment was held on file. The Manager reported that all staff work supervised in the period from when their clearance from the protection of vulnerable adults (pova) list is returned until their Criminal Records Bureau (CRB) clearance is returned, however they were not able to demonstrate this in writing apart from reporting that all staff work in pairs. The provider has standard systems which they use for the induction of new staff. These comply with current guidelines. All new members of staff are given a copy of the standard booklet. Records showed that staff worked their way through this booklet, supported by relevant people. New members of staff receive supervision at six weeks and three months after their employment. We received a variable response about induction from staff in questionnaires. Two staff reported that the induction very well, six mostly, one partly and one not at all covered everything that they needed to know when they started their role. We discussed induction with staff during the inspection. Staff told us that they worked two to three days supernumerary when they started. Two people reported that they had done a similar role before and so knew what to do. Two newly employed people, including one domestic, described areas covered on induction, including COSSH, manual handling, infection control and protection of vulnerable adults. None of the people we spoke to reported that they felt that their induction had not covered what they needed to know. In their annual quality assessment, the home reported that they had improved training and were seeking to support people in National Vocational Qualifications (NVQs). People who commented on training nearly all felt that they were given training adequate for their role. Several people we spoke with during the inspection reported Care Homes for Older People Page 28 of 38 Evidence: on the supports to training, including ancillary staff, as well as carers and registered nurses. One person reported, Ive done so many about the training courses they had done. The home has a clear training matrix, which helps management identify what training staff have done and who is due to attend what training. One carer described the dementia care course they had recently undertaken and how interesting they had found it. As well as supporting carers in NVQs, the home also support ancillary staff in gaining NVQs relevant to their role. One resident commented, Avonmead management, SRNs, care workers, chef etc are all very helpful and looks after everything to my needs excellently. Care Homes for Older People Page 29 of 38 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents will have the benefit of living in a home which is well managed and where systems for quality of service provision are regularly reviewed. Evidence: Mrs Cottrell, the manager of Avonmead has been in post for an extended period of time, she is an experienced manager and registered nurse. She is supported by a deputy, who has recently been appointed. This person has also been employed by the home for an extended period of time as a registered nurse. Both the manager and her deputy have recently been trained in a range of areas by the provider, along with other managers and their deputies from sister homes. A new operations manager came into post a year before this inspection, this person works with the home to provide additional management support, when needed. The home has clear, auditable systems for the management of residents moneys. All charges for services such as hairdressing and chiropody are dealt with by invoicing systems. The administrator had a clear understanding of her role in relation to residents finances. Care Homes for Older People Page 30 of 38 Evidence: Four Seasons Healthcare, the provider, has established systems for assessing quality of care provision. This assessment covers a range of areas. Residents and other key persons are asked to comment on quality of service and if issues are identified, the home is required to develop an action plan to detail how areas will be addressed. For example in the most recent questionnaire, issues were identified about the garden and an action plan was developed to make the garden more attractive. The home also puts in regular returns relating to quality of clinical service provision, such as incidences of pressure ulceration, infection, serious changes in health status for residents, accidents and reviews of complaints. This ensures that the provider is able to review quality outcomes for residents. The home has a regular system for internal reviews, which senior staff undertake, including review of medication procedure, care plans and health and safety. These are periodically verified by a more senior manager. A manager from the company also visits the home regularly and completes a report. It was noted as good practice that these reports identified issues and actions to be taken to address them, as well as commenting on good practice. We reviewed systems for ensuring health and safety. We observed two members of staff assisting a person in moving by using a hoist. They performed the role safely, in accordance with guidelines, advising the person of what they were doing throughout. The home has safe systems for the use of bed rails. We reviewed the maintenance log and it was clear that staff documented issues that needed attention and that action was taken to address them. We reviewed the planned maintenance systems, including fire safety and observed that full records were maintained. All residents who needed Oxygen and all areas where Oxygen was stored had relevant signage in place. One Oxygen cylinder in a store room had not been secured, this is required due to the risk to people if Oxygen cylinders topple over. Care Homes for Older People Page 31 of 38 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 32 of 38 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 8 12 The home must perform a quality review of communication systems in the home, to ensure that all staff are given the information that they need to ensure that they are aware of individuals current and changing needs and how individuals needs are to be met. Staff need to be given full information on residents needs, so that they can be sure that they are able to meet the persons needs. 29/05/2009 2 8 12 The home must ensure that all staff work to consistently reduce risks of pressure ulceration to residents. All care plans must be clear, fully direct staff on actions to take to reduce risk and comply with guidelines. Where a person needs their position changing regularly to prevent pressure 29/05/2009 Care Homes for Older People Page 33 of 38 ulceration, records must show that they have had their positions changed in accordance with guidelines and their care plan. Pressure ulcers, once sustained can take an extended period to heal, be very painful and present a risk of infection. Therefore care must always be provided in accordance with research-based guidance, to prevent pressure ulceration from occurring. 3 8 13 People who are prescribed 15/05/2009 oxygen or medication via a nebuliser, must always have care plans put in place to direct staff on the frequency of cleaning, drying and changing of equipment. People who are administered drugs via a nebuliser or oxygen, are at risk of infection if the equipment used is not clean, dry and regularly changed. 4 9 13 Where a monthly medicines administration record has been completed, empty spaces underneath completed records must never be used to document the following months medicines administration instructions. In order to prevent risks of medication error, all medication administration 15/05/2009 Care Homes for Older People Page 34 of 38 records must be clear and sequential. 5 9 13 Where medications are 29/05/2009 prescribed as directed, there must always be a care plan or protocol to direct staff on when and how often such drugs are to be administered. Protocols or care plans for as directed medication ensure that all registered nurses administer such medication in a consistent manner in accordance with the persons needs. 6 9 13 All medicines which are to be sent for disposal must be safely stored. Medicines for disposal are categorised as clinical waste. As such they have the potential to present risk to people. Therefore they must always be stored for disposal in accordance with guidelines. 7 26 13 When handling used linen, staff must always wear an apron and ensure that linen skips are close at hand. Used laundry can be a source of cross infection. Therefore the front of a member of staffs uniform must always be protected by an apron when handling used laundry. Risk of crossinfection is reduced if used laundry is quickly placed in a 15/05/2009 15/05/2009 Care Homes for Older People Page 35 of 38 linen skip for transfer to the laundry and not be carried along the corridor. 8 26 13 The upstairs sluice room and 15/05/2009 downstairs clean storage cupboard must be kept in a tidy state. If these rooms are not tidy, access to hand washing facilities will be affected and sterile items can be damaged. This can lead to risks of cross infection. 9 29 18 All staff files must include an 26/06/2009 up-to-date picture of the person, to provide positive proof of identity. Establishing proof of identity is an important part of safe recruitment procedure. An up-to-date photograph of the individual is a key area in proof of identity. 10 38 13 Oxygen cylinders must always be fully secured. Oxygen cylinders, due to their shape, may topple easily and if they do so, have the potential to cause injury, therefore they must always be fully secured. 15/05/2009 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 7 All care plans should state the type of continence pad to be used for the resident. Page 36 of 38 Care Homes for Older People 2 3 7 9 Where a person has a urinary catheter, the clinical indicator for use of the catheter should always be documented. Where a person is regularly prescribed a drug which can affect their daily lives, such as aperients or painkillers, all people should have a care plan to direct staff on why the person needs the drug. This care plan should be regularly evaluated to ensure that the benefit of the drug to the resident can be evaluated. Jars of topical creams should all be labelled with the persons name. As far as possible commode chairs should be labelled with the persons name and used only for that person. Disposable gloves in wcs and en-suites should be placed in wall dispensers. Where the providers human resources department has performed a risk assessment on a prospective employees suitability if the person has issues identified in their CRB, copies of this assessment should be retained on the member of staffs file in the home. The home should develop clear records to demonstrate that new members of staff are working supervised in the period after their pova clearance is obtained and before their CRB check is returned. 4 5 6 7 25 26 26 28 8 29 Care Homes for Older People Page 37 of 38 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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