Inspection on 28/10/05 for Avonwood Manor

This inspection was carried out on 28th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

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 25/04/06

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 Unannounced Inspection 09:00 28 October 2005 th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000043057.V252305.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. DS0000043057.V252305.R01.S.doc Version 5.0 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 Mrs Toni Sylvana Stevens 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.V252305.R01.S.doc Version 5.0 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. 26th May 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.V252305.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place between 9am and 3.15pm with Mrs Stevens, the registered manager assisting throughout the inspection. Due to the mental frailty of the residents it was not possible to gain an account of their experience of living at the home. A period of time was spent talking with five members of staff and observing staff working with residents. The remainder of the inspection was spent with Mrs Stevens in the office assessing the records and practices of the home. What the service does well: What has improved since the last inspection? What they could do better: When new staff are appointed they must not start working in the home until a CRB has been returned or a satisfactory POVA First check received. It was recommended that the staff application form be amended so as to request the information demanded by the changes in the Regulations of July 2004. Mrs Stevens reported that she intends to develop better lines of communication with the staff and the management. DS0000043057.V252305.R01.S.doc Version 5.0 Page 6 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.V252305.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000043057.V252305.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Residents benefit from a full assessment of their needs being carried out prior to their being offered a place at the home. EVIDENCE: The pre-admission procedures were discussed with the manager. Referrals to the home are usually through the care management system. An initial enquiry form is completed and invitations are made for the person or their representative to visit the home. It was reported that either the registered manager or the deputy manager then go and visit the person referred and carry out an assessment of need. The home uses a form that is detailed and covers all the areas of assessment identified within the standards. A sample of two residents files were viewed and it was found that a full pre-assessment of need had been carried out prior to their being offered a place at the home. It was also reported that a copy of the care management assessment is obtained as part of this assessment process. The home does not provide a service for intermediate care. DS0000043057.V252305.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 9 10 Residents benefit from a system whereby care plans are kept up to date and reflect their changing needs. The medication systems have been updated to reflect best practice. Staff respect resident’ privacy and dignity. EVIDENCE: At the last inspection it was noted that staff were working to a care plan that was out of date. The system for updating care plans was therefore discussed at this inspection with the staff and the manager. It was reported that any changes of a resident’s needs are discussed during staff handovers with one of the two care co-ordinators who are accountable for care in the two sections of the home. The required changes are then communicated to the manager or deputy who update the care plan on the computer. The reviewed plan is then printed and a copy put in the care plan folder that is available to the staff. A sample of two care plans were viewed and these demonstrated that the plans are updated or reviewed at least monthly or when needs have changed. The system was found to be effective in keeping staff informed of residents’ changing needs. It was reported that residents are involved in the care planning to the extent that their mental capacity allows and that relatives are invited to sign care DS0000043057.V252305.R01.S.doc Version 5.0 Page 10 plans or to have a copy should they wish. Copies of care plans and risk assessments are kept locked in a cupboard and staff have easy access to these. The staff spoken with said that maintaining dignity and respect for residents was a high priority. All the shared rooms have screens for promoting privacy and doors are closed when residents are receiving personal care. Staff knock on bedroom doors before entering. Residents clothing is labelled with their names to ensure that they wear their own clothes. Relatives are asked to complete a history questionnaire so that the staff can be made aware of personal preferences and the choices residents would wish staff to respect. A full audit of the standards relating to medication administration was not carried out, however it was found that the requirement concerning crushing and covert medication administration had been complied with. The need for covert medication administration is discussed with the GP who then signs a consent form if this is deemed a necessary procedure. The recommendations that two people sign the medication administration records when a medicine has needed to be added to the printed sheet has been adopted, so too the recommendation of recording the start date for the unit dosage system. DS0000043057.V252305.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 Residents are provided with appropriate activities and are supported to maintain contact with their families. EVIDENCE: As mentioned earlier in the report, resident’s relatives are invited to complete a form that provides a history of a resident’s life so that the home can try and accommodate their needs. A sample of these was viewed and cases where these had been used to meet residents needs were discussed. As the residents are not able to leave the home entertainers are regularly brought into the home. An activities coordinator is also employed at the home and works five days a week. On the day of inspection the inspector observed activities being held with residents participating. The Statement of Purpose and the brochure sent out to relatives informs that visitors are welcome at any time. DS0000043057.V252305.R01.S.doc Version 5.0 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not inspected on this occasion. EVIDENCE: DS0000043057.V252305.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 Residents benefit from a safe, well-maintained environment. EVIDENCE: On the day of inspection the home was found to be clean and in reasonable decorative order throughout. The home maintains a locked door policy to ensure that residents cannot wander and get lost from the home. The home meets standards for fire protection and it was found that tests and inspections to the fire safety system have been carried out to the required timescales. At the last inspection a requirement was made that the home ensure that hot water did not exceed 43 degrees for hot water outlets to protect residents from the possibility of scalding. The inspector was informed that thermostatic mixer valves had been fitted to all hot water outlets. One bathroom tap was tested and the water was found to meet this standard. DS0000043057.V252305.R01.S.doc Version 5.0 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28 29 30 Staffing levels were meeting the needs of the residents and the staff team is provided with appropriate training. The residents would be better protected by the recruitment procedures being more tightly applied. EVIDENCE: The home continues to provide the same levels of staffing as at the time of the last inspection. The home is divided into two sections, Nelson and Selbourne and there is a Senior Care Coordinator who accountable for the residents in their designated sections. The senior carers and care assistants provide care to the residents. The staff rota reflected that three care staff are employed throughout the day between 8am to 8pm on each of the two sections of the building and one member of staff works across both sections. Mrs Stevens was able to show that the home uses a resident’s need assessment tool that takes into account the dependency levels of the residents in determining staffing levels. The staff spoken with said that the levels of staff were sufficient to meet the needs of the residents. The home also employs 2 laundry staff, 2 chefs, 2 cleaners, a maintenance person, kitchen assistant and administrator. The home employs a staff team of 22 carers of whom 16 have completed NVQ level 2. The manager was able to provide comprehensive training records for all of the staff and these revealed that training was being provided to staff in core areas such as manual handling, first aid, fire safety, medication administration and abuse awareness. DS0000043057.V252305.R01.S.doc Version 5.0 Page 15 The recruitment records for two staff employed at the home since the time of the last inspection were viewed. It was found that all the necessary checks had been carried out, however both had started work in the home doing shadow shifts with another worker before the CR and POVA First check had been returned. It is a requirement that staff should not work in the home until these checks have been returned. It was recommended that the staff application form be amended to obtain information from candidates in line with changes to the Regulations of July 2004. DS0000043057.V252305.R01.S.doc Version 5.0 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 33 The home is well managed and is run in the interests of the residents. EVIDENCE: Mrs Stevens was a trained RMN and has a long career working in the statutory, voluntary and private sector. She holds an NVQ level 5 in organisational management and two remaining elements remaining before completing the Registered Managers award. Regulation 26 reports (reports carried out by one of the managers of the organisation) are being undertaken each months required. In terms of quality assurance, one of the staff spoken with said the reason they felt they provided a good service was that the home was run in the interests of the residents. Surveys are carried out taking into account the views of relatives and a quality audit using a template devised by BML healthcare has been undertaken. DS0000043057.V252305.R01.S.doc Version 5.0 Page 17 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 x 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 x 3 X X X X X X x STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 X X X X X DS0000043057.V252305.R01.S.doc Version 5.0 Page 18 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 You are required to ensure that staff do not start working at the home until their CRB or Pova First check has been returned Timescale for action 07/11/05 1 OP29 19 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP18 Good Practice Recommendations It is recommended that the staff application form is reviewed to comply with the changes in Regulations of July 2004. DS0000043057.V252305.R01.S.doc Version 5.0 Page 19 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.V252305.R01.S.doc Version 5.0 Page 20 - 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. 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