Inspection on 25/04/06 for Avonwood Manor

This inspection was carried out on 25th April 2006.

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

Avonwood Manor 08/12/09

Avonwood Manor 12/11/09

Avonwood Manor 20/10/09

Avonwood Manor 21/09/09

Avonwood Manor 17/06/09

Avonwood Manor 13/05/08

Avonwood Manor 25/07/07

Avonwood Manor 28/10/05

Avonwood Manor 25/05/05

Avonwood Manor 27/01/05

Avonwood Manor 16/04/04

Similar services:

Trevaylor Manor

Stallcombe House

Stroud Lodge

The Woodmill

Woodland Vale

Bolealler House

Claremont Nursing Home

Althea Park House

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

CARE HOMES FOR OLDER PEOPLE Avonwood Manor 31-33 Nelson Road Branksome Poole Dorset BH12 1ES Lead Inspector Martin Bayne Key Unannounced Inspection 08:45 25th April 2006 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 DS0000043057.V291536.R01.S.doc Version 5.1 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. DS0000043057.V291536.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Avonwood Manor Address 31-33 Nelson Road Branksome Poole Dorset BH12 1ES 01202 763183 01202 751530 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) Avonwood Manor Ltd Care Home 49 Category(ies) of Dementia - over 65 years of age (49), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (49) DS0000043057.V291536.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. One named person (as known to CSCI) under the age of 65 may be accommodated to receive care. 28th October 2005 Date of last inspection Brief Description of the Service: Avonwood Manor is registered to provided accommodation and personal care for up to 49 residents who suffer from mental health disorders or dementia above the age of 65. The home is owned by Avonwood Manor Ltd but is managed through agents, BML Healthcare Ltd. The home is situated in a quiet residential area close to the shops and amenities of Westbourne, and is made up of two large properties that have been joined by an extension. Each of the properties has three floors and there is a passenger lift at either end of the home. Communal areas are located on the ground floor and there are well-maintained gardens leading from the back of the home that the residents can access. The gardens are enclosed to ensure the safety of the residents. The majority of the bedrooms are for single occupancy with en-suite WC facilities, however there are eight double rooms, in which screens are provided for resident’s privacy. To the front of the home there is parking for staff and visitors. DS0000043057.V291536.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place between 8.45am and 3pm. The newly appointed Registered Manager, Mrs Phillips assisted throughout the inspection, explaining how the service is run and providing records as documentary evidence. The inspector was also able to speak with some of the residents and with three members of staff. Due to the mental frailty of the residents it was not possible for them to give an account of life at the home. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. DS0000043057.V291536.R01.S.doc Version 5.1 Page 6 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 DS0000043057.V291536.R01.S.doc Version 5.1 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A full assessment of need is undertaken prior to a person being offered a place at the home in order to ensure that their needs can be met. EVIDENCE: Throughout the inspection a sample of three residents’ files, all of whom had been admitted to the home since the time of the last inspection in Oct 2005, was used to track the required records that need to be kept in the home. In the case of these residents a pre-admission assessment had been carried out to determine that the home could meet their needs, this being recorded on a form devised for this purpose. The manager or her deputy undertake the assessments and visit the person in their own home, hospital or if possible invite the person with their relatives to the home. The three residents were all privately funded and their relatives had been instrumental in choosing the home. Avonwood Manor does not provide an intermediate care service. DS0000043057.V291536.R01.S.doc Version 5.1 Page 8 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 9 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents care needs are met through care plans being developed through the assessment process. Health needs are met through monitoring residents and the care planning system. The home has systems, policies and procedures for the safe administration of medicines. Staff maintain respect for residents and pay attention to their dignity. EVIDENCE: Once a person is admitted to the home their needs are fully assessed and a plan of care is developed. With the assistance of relatives, the home will try and build up a short life history as this can assist in understanding the needs of the person concerned. In the case of all three residents tracked, there was a full typed and dated care plan. Due the mental frailty of the residents, they DS0000043057.V291536.R01.S.doc Version 5.1 Page 9 are not able to read and understand their care plans and so relatives are invited to have a copy should they wish. A record was seen of one case where the plan had been sent to a relative. Evidence was also seen that the plans were updated monthly or when needs had changed. Staff are also required to complete monitoring sheets relating to personal care which provide a record that the care plan has been carried out as specified in the care plan. The care plans were found to make reference to written risk assessments completed when a specific risk had been identified. Examples seen were in relation to moving and handling of residents, and how to approach one resident who could present on occasion with challenging behaviour. The residents tracked through the inspection were all found to be registered with a GP. Examples of how the home met the resident’s health needs were documented on file. One resident, having been assessed by the staff as being over medicated, was referred for a medication review with their GP. Another had been referred for a suspected urinary tract infection and in another situation the home had been assisted through a referral to a CPN. Mrs Phillips informed that the where possible health professionals are invited to the home, as residents can find appointments to hospitals or other venues frightening. The inspector was able to see evidence that chiropodists, dentists and opticians visit the home to attend to residents’ needs. The home has full policies and procedures for dealing with medication in the home. Due to the fact that all of the residents suffer from dementia, all are unable to manage their own medication and the home undertakes the responsibility for administration of medicines. Within the last year the home has had a full pharmacy inspection and has complied with the requirement and recommendations made at that time. The home is divided into two sections, Nelson and Selbourne, linked together by a corridor. The medication procedures for Selbourne section were inspected. The home has an arrangement with a local pharmacist who delivers medicines in a unit dosage system to the home. These are stored in a locked trolley on one of the landings. Medications for an individual resident are taken from the unit dosage containers, decanted into a small pot and then taken to the person. Once the medicines have been taken, the staff then record this on the medication administration record. For one of the residents tracked through the inspection there was a record by the GP that the staff may crush tablets for that person. In another case the family had informed that one resident was allergic to penicillin. This has been recorded on the care plan and the manager had informed the pharmacy so that this information can be recorded on the printed sheet supplied by the pharmacist. The medication administration records for all of the residents were seen and it was found that these had been completed correctly with no gaps in the record. All of the staff who administer medication have received training wither through the pharmacist or through the trainer employed through BML Healthcare. DS0000043057.V291536.R01.S.doc Version 5.1 Page 10 The inspector discussed with the manager how the respect and dignity of residents is promoted within the home. In the case of one of the residents tracked through the inspection he is dressed in a shirt and tie each day as this reflected his choice prior to the onset of his illness. In the case of another resident staff address this person not by their Christian name, but the name of their choice. Residents are all dressed in their own clothes and through the their life histories provided through their relatives, their individual choices are respected. Personal care is provided in the privacy of their own room. In the shared rooms, screens are provided. All of the residents seen looked cared for being clean, hair and nails attended to and dressed in clean clothes. DS0000043057.V291536.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home endeavours to meet the expectations and preferences of residents. Residents at the home are encouraged to maintain contact with friends and relatives, who can visit at any time. Staff support residents to exercise choice and control over their lives. Resident’s dietary needs are met and monitored with a wholesome and varied menu of food provided. EVIDENCE: By obtaining a life history of each resident through the assistance of their relatives, the home is able to meet the lifestyle expectations of each resident. The religious needs of the current resident group are met though a Church of England service being held in the home every fortnight and a Catholic service also being held. Mrs Phillips reported that should a person be admitted with other religious and spiritual needs the home would take steps to meet these. DS0000043057.V291536.R01.S.doc Version 5.1 Page 12 On the day of inspection there were no relatives visiting residents, however the care records detail when each resident receives a visitor and it was clear that visitors are welcome at the home. Mrs Phillips informed that all of the residents apart from two have contact with family of friends. Relatives are also able to maintain contact by phone should they be unable to visit. Visiting can take place at any time that suits residents. Relatives are able to take residents out of the home when they visit. With regards to residents’ choice and control over their lives, Mrs Phillips informed that residents are able to get up go to bed when they choose, although residents are encouraged to get up before 11am. Residents are able to wear the clothes of their choice and are free to access all areas of the home and gardens. The home however does have a locked door policy in order to ensure that residents do not wander from the home and get lost. This is clearly detailed within the Service User Guide so that relatives are informed before a person is admitted to the home. It was noted that likes and dislikes of food were recorded and respected. They are also able to bring their own possessions to personalise their rooms. Breakfast is served between 7am and 9am in the dining room. Should a person be unwell they are able to remain and have meals within their room but generally residents are encouraged to eat in the dining areas. The main meal of the day is served at approximately midday with a light meal served in the evening. The main meal of the day was seen and also the records of food provided to residents, which reflected a wholesome and nutritious diet. Individual records are maintained of what each resident has eaten and also some indication of quantity in order to monitor any changes in appetite, indicating possible ill health. The care plans reflect the assistance required by each resident, whether they need their food pureed or need assistance with eating by the staff. Mrs Phillips reported that on occasion a resident has been referred to a dietician if this has been required. Some residents are also supplied with ‘build-up’ drinks to supplement dietary food intake. DS0000043057.V291536.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has full complaints procedures that are well publicised. The home has policies and procedures and a training programme for the staff to protect residents from abuse. EVIDENCE: The complaints procedure for the home is displayed in the main reception area, the manager’s office and also in the Service User Guide and Terms and Conditions of Residence. Relatives are each given a copy of the Service User Guide, so are informed of how to make a complaint. Due to their dementia, the residents themselves are unable to make complaints themselves and rely on third parties to make complaints on their behalf. The complaints procedure complies with the format detailed within the Standards for Older People. Since the time of the last inspection there have been no complaints made to the management of the home and none have been brought to the attention of CSCI. The home maintains a log of all complaints made about the service. All of the staff receive training in adult protection issues and abuse with a training session held in February 2006 and another scheduled for June. In the past the management through reporting by the staff have taken action against a member of staff, who was subsequently put on the POVA register, (listing staff who are not permitted to work with vulnerable adults). The home has copies of all the relevant policies and procedures for the protection of vulnerable adults. The home also has leaflets from an advocacy scheme should a resident require their services. DS0000043057.V291536.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s benefit from a well maintained and safe environment. Infection control policies and procedures ensure that the home is clean and hygienic. EVIDENCE: The home is located in a quiet residential area close to the amenities of Westbourne. The home was found to be in good decorative order both externally and internally. The buildings have a homely feel with well maintained gardens to the rear of the property, to which residents have free access. At the front of the home there is car parking for staff and visitors. The home has a locked door policy for the protection of the residents and this is detailed within the Statement of Purpose and Service User Guide. During the inspection a tour of the building was made and the home was found to be clean and generally free from adverse odours. The home has carpets DS0000043057.V291536.R01.S.doc Version 5.1 Page 15 throughout and the two cleaners have carpet cleaners and spillage kits to maintain a clean environment. All of the radiators have been covered and there are thermostatic mixer valves fitted to the hot water outlets of baths to protect residents from burns and scalding water. Since the last inspection the kitchen floor has been re-laid as recommended by the Environmental Health Officer. With regards to infection control the home has policies and procedures for the staff to minimise the risk of cross infection. Staff are provided with gloves and aprons, which they were observed to be wear as appropriate. Staff are also provided with alcohol hand gels. The home has a sluice area fitted with a macerator for the disposal of used pads. The home has a dedicated laundry room fitted with four commercial washing machines and three commercial driers. Two laundry staff are employed at the home. The laundry room has washable floor and wall surfaces and hand washing facilities are provided. DS0000043057.V291536.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 28 29 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides sufficient staff to meet the needs of the residents. The recruitment procedures are now robust to ensure protection of residents. Staff receive appropriate training for them to carry out their roles effectively. EVIDENCE: The home continues to provide the same levels of staffing as at the time of the last inspection with seven care staff on duty between 8am to 2pm, six staff between 2pm and 8pm and four staff on awake night duty between 8pm and 8am. A rota was seen reflected the above staffing levels. In addition the home employs a registered manager, deputy, administrator, cleaners, cooks and laundry staff. Out of hours there is an on call manager available to the staff. The staff spoken with and Mrs Phillips all felt that the staffing levels met the needs of the current resident population. It was reported that generally there was little use of agency staff within the home and there is a core of staff who have worked for a long time at the home. At the time of inspection about 45 of the care staff team had completed NVQ level 2 or equivalent. DS0000043057.V291536.R01.S.doc Version 5.1 Page 17 At the last inspection a requirement was made concerning recruitment procedures as it had been found that some staff had started work prior to a POVAFirst check having been undertaken. A sample of three staff files was viewed for staff who had been employed at the home since the time of the last inspection. It was found that all of the required checks and records were in place and all staff had had a POVAFirst check before starting work at the home. With respect to training, all new staff receive induction training and records this for the staff tracked were seen. Staff are offered training in core areas such as; fire safety, infection control, abuse, moving and handling, principles of care and health and safety. Further training is also offered in areas such as dementia, food hygiene, first aid and medication. Mrs Phillips informed that her aim was to provide better training in dementia and a new course for the staff was due to take place shortly. DS0000043057.V291536.R01.S.doc Version 5.1 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 33 35 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is effectively managed. The home has quality assurance systems in place to ensure that the home is run in the interest of the residents. The health and safety of residents is promoted within the home. EVIDENCE: Shortly after the last inspection in Oct 2006 the then registered manager ceased working at the home and a new manager, Mrs Phillips has been appointed and registered with CSCI. It has been agreed with Mrs Phillips that she gains qualifications to NVQ level 4 in management and care or equivalent. DS0000043057.V291536.R01.S.doc Version 5.1 Page 19 Mrs Phillips has worked for many years prior to this appointment as the Deputy Manager. The staff spoken with said there was friendly, cohesive staff team who felt well supported through the management. The home has recently carried out a quality assurance survey involving relatives of residents at the home, the results of which were seen. The feedback was positive in relation to the standards of care in the home. The inspector was also able to view the five letter of thanks sent to the manager since the last inspection. Regulation 26 visits and reports, where a representative from the organisation visits the home, have been carried out each month as required. The home does not get involved in managing any residents’ finances with relatives appointed solicitors or the Court of protection undertaking these responsibilities. In respect of safe working practices it was found that the fire safety system was being tested and inspected to the required timescale. Risk assessments in respect of the working environment have been carried out and the accident books were seen, providing evidence that accidents were being recorded correctly. DS0000043057.V291536.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X N/a X X 3 DS0000043057.V291536.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? No 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 DS0000043057.V291536.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © 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 DS0000043057.V291536.R01.S.doc Version 5.1 Page 23 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!