Inspection on 19/06/06 for Addenbrooke Care Home

This inspection was carried out on 19th June 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

Addenbrooke Care Home 12/10/07

Addenbrooke Care Home 21/09/05

Addenbrooke Care Home 20/04/05

Addenbrooke Care Home 19/11/04

Addenbrooke Care Home 22/07/04

Addenbrooke Care Home 25/02/04

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

CARE HOMES FOR OLDER PEOPLE Addenbrooke Care Home Willis Road Gosport Hampshire PO12 1NA Lead Inspector Marilyn Lewis Unannounced Inspection 19th June 2006 10:00 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 Addenbrooke Care Home DS0000039545.V294073.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. Addenbrooke Care Home DS0000039545.V294073.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Addenbrooke Care Home Address Willis Road Gosport Hampshire PO12 1NA 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) 023 9258 1088 jonnt.msmith@hants.gov.uk Hampshire County Council Susan Joan Webber Care Home 35 Category(ies) of Dementia - over 65 years of age (35) registration, with number of places Addenbrooke Care Home DS0000039545.V294073.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st September 2005 Brief Description of the Service: Addenbrooke is a registered care home providing personal care to 35 service users who are over the age of 65 years and who have dementia. The home is situated close to the town of Gosport, the water front and some local amenities. Accommodation is arranged in four units, each with a number of bedrooms, a bathroom and toilet facilities, lounge, dining area and kitchenette. A passenger lift and stairs allow access between the two floors. All service users have single rooms that are fitted with wash hand basins. The service also benefits from gardens that are enclosed and accessible to service users. At the time of the inspection the fees for the home were at the Hampshire County Council rate of £434 per week. Addenbrooke Care Home DS0000039545.V294073.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over two days, the 19th June and 4th July 2006. On the first visit to the home the inspector toured the home, spoke with six service users, a visiting relative, a district nurse, three care staff members and two assistant unit managers. Records were seen including care plans, medication records, staff training and supervision, fire safety and drills and checks on services such as electricity and specialist equipment. On the second visit the inspector met with the registered manager and looked at records for staff training and recruitment and the activities programme. What the service does well: Service users said that staff were ‘lovely’ and ‘very caring’ and a visiting relative also commented on the friendliness and caring attitude of staff. Staff were observed interacting with service users in a relaxed but respectful manner. Care needs assessments are undertaken for all service users before they are admitted to ensure the home can meet their care needs. Service users health care needs are met and they are protected by the home’s clear procedures for dealing with medicines. The home provides a varied programme of activities that are suitable for the service user group and are arranged taking into account the service users interests. Meals served at lunch offered choice, looked appetising and were well presented. Service users said that they enjoyed the meals provided at the home. Service users and their relatives know that any complaints raised will be acted upon. The home provides a clean, safe environment for those who live and visit there. Service users liked their rooms, which contained many personal items and looked comfortable and homely. Staff said they were encouraged by the registered manager to attend relevant training sessions. Staff also receive regular supervision. Addenbrooke Care Home DS0000039545.V294073.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Care plans had improved and were comprehensive but required a little more attention to detail to ensure all the care needs were identified. Some care plans showed evidence of the service user or their relative’s involvement in the development and review of the plans. However, although staff were observed to discuss changes to care needs with service users and if appropriate their relatives, this was not always noted on the care plans. Although staff spoken with were aware of the procedures to follow should abuse be suspected, some staff had not attended training in protecting service users from abuse. A recommendation has been made for the medicine storage to be moved from the current room to a more suitable room with hand washing facilities for staff. During the first inspection visit, staffing levels allowed for only one carer for each of the four units. When a service user required the assistance of two staff members, a carer left the unit she was on and went to assist, leaving a unit without staff. The inspector observed a unit without a staff member for twenty minutes. This was a cause for concern as the home provides care for service users with dementia. On the second visit to the home six carers were on duty, enabling assistance to be given without leaving the unit unattended. The registered manager has been required to review the staffing levels to ensure sufficient staff are on duty at all times. Fire records seen indicated that not all staff had attended a fire drill in the last year. Addenbrooke Care Home DS0000039545.V294073.R01.S.doc Version 5.1 Page 7 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. Addenbrooke Care Home DS0000039545.V294073.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Addenbrooke Care Home DS0000039545.V294073.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 5 and 6 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to the service. Prospective service users and their relatives have the information required to make a decision about life at the home and know that a care needs assessment will ensure the home can meet their needs. EVIDENCE: Prospective service users are provided with an information pack containing the home’s Statement of Purpose and Service User Guide. The documents give clear information about life at the home including the organisational structure and the procedures for admission. Details for staff qualifications needs to be more detailed to indicate how many care staff members actually hold or are in the process of obtaining, National Vocational Qualifications (NVQ). Written contracts giving details of the terms and conditions for residency at the home were seen in the records for four service users, case tracked during the inspection visit. Addenbrooke Care Home DS0000039545.V294073.R01.S.doc Version 5.1 Page 10 Service users records contained an assessment of care needs completed by their care manager before admission and also a care needs assessment undertaken by staff at the home. Information from relatives was included in the care assessments. Records seen indicated that the care assessments were reviewed to reflect the changing needs of the service users. On the day of the inspection visit, one service user was due to move to a nursing home as the home was unable to provide the care now required due to changes in the care needs. A relative of the service user said that communication with staff at the home had been very good and they had kept her up to date on all the service users care needs and their ability to provide a service to meet the assessed needs. The relative said that they had the opportunity to visit Addenbrooke before admission and that she had been encouraged to visit the home the service user was to move to before agreeing with the transfer. The home provides respite care but does not provide intermediate care. Addenbrooke Care Home DS0000039545.V294073.R01.S.doc Version 5.1 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to the service. Service users feel they are treated with respect and are protected by the home’s clear procedures for dealing with medicines. Some care plans require more attention to detail to ensure information is up to date and agreed with the service users or if appropriate their relatives. EVIDENCE: The care needs assessments form the basis for the individual care plans. Care plans were seen for four service users to be case tracked during the inspection visit. The plans included assessments for moving and handling, bathing, nutrition and falls. The plans although detailed, require more information such as in the case of one service user who had broken their dentures. This was noted in the daily contact sheet but the review of the plans stated that there was no change to the plans and did not indicate there was an issue with the dentures. Another plan indicated that a service user was awaiting a visit by the community psychiatric nurse to advise on behaviour issues but there was no risk assessment or care plan for behaviour. The assistant unit manager on duty Addenbrooke Care Home DS0000039545.V294073.R01.S.doc Version 5.1 Page 12 during the inspection visit produced a care plan, for behaviour, for the service user at the time of the inspection. Two service users had signed their care plans but the other two plans did not provide any evidence of the service users or their relatives involvement. The assistant unit manager said that the plans were discussed with service users and if appropriate their relatives. During the inspection visit it was noted that a staff member spoke with a relative on the telephone to update them on changes to the care needs of a service user. However these conversations were not always entered on the plans. It was agreed that these discussions would be noted in the plans. Care plans seen indicated that service users health care needs were met. Visits from GPs, district nurses, community psychiatric nurses, physiotherapist and opticians were noted in the plans and appointments for clinics such as the memory clinic were also documented. A service user spoken with said that she was able to see her GP when she felt she needed to, by asking staff for a home visit. A district nurse visiting at the time of the inspection visit said that staff were very good and followed advice and instructions given. At the time of the last inspection not all medicines administered had been recorded on the medication records. On this inspection visit medication records seen had been completed appropriately. Procedures were in place for the recording of all medicines entering the home and on disposal of unwanted items. Only the assistant unit managers and the night co-ordinators administer the medicines. All have received training in the administration of medication. At the time of the inspection no service users were prescribed medicines that required storage and recording for controlled drugs. There were no service users who were responsible for administering their own medication. One service user said that they liked staff to ‘look after their tablets’. Information sheets were available on medicines in use at the home. The room used to store medication is very small and unsuitable for the purpose as there are no hand-washing facilities. Staff said that they found it very difficult to work in the cramped conditions. At the time of the last inspection visit, staff also stated that the room was unsuitable for the use of storing medication and that an unused room on the first floor would be more appropriate. It is recommended that the medication room be moved to a more suitable space. During the inspection visit staff were seen to speak with service users in a caring and respectful manner. A service user said that the ‘staff were lovely’ and a visitor said that staff were ‘always very caring’. Addenbrooke Care Home DS0000039545.V294073.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to the service. Service users are offered the opportunity to participate in a range of suitable activities, are able to exercise control over their lives and enjoy a choice of appetising, well presented meals. EVIDENCE: The home employs to support workers who are responsible for providing an activities programme for the service users. On the day of the inspection visit, one of the support workers was away from the home due to sickness and the other was working on one of the units due to staff shortages. Only one staff member was on duty for each of the four units so it was not possible for any activities to be supported that day. The activities programme indicated that music to movement took place on Fridays and there were also events for groups, such as sing-a-longs, puppet shows and visits from local schoolchildren. The assistant unit manager said that one to one activities included nail care, gardening, reminiscing and shopping trips. A service user spoken with said that she enjoyed laying the tables for lunch and helping with washing up and she was involved in these activities at lunchtime. Addenbrooke Care Home DS0000039545.V294073.R01.S.doc Version 5.1 Page 14 On the second visit to the home, one of the support workers had arranged for some service users to paint a banner. One of the service users said that she was enjoying the session. The support workers have documented each service users likes and dislikes for leisure activities and have drawn up a programme of activities using this information. Records for the activities undertaken by service users were kept and these indicated that they were involved in a variety of activities including chatting with local school children who visited the home, card games, making birthday cards and gardening. Small details were recorded, for instance, the records for one service user said that while a blackboard was being used with chalk, the service user who did not participate in drawing or writing on the board, enjoyed getting chalk on their fingers. The records also indicated that service users went with a support worker for walks into the town and to the coast on a one to one basis. A local minister visits the home and conducts a service on a six-weekly basis. Two care plans seen indicated that the service users did not wish to attend services but did enjoy watching special services, such as at Easter, on the television. During the inspection staff were observed supporting service users to make their own decisions. Before lunch service users were asked which flavour drink they would like and were offered some to taste to help them make their decision. Service users were also asked if they would like to sit in the lounge or dining area or stay in their own room, following lunch. The home has a menu that indicated that service users were offered a choice and variety of meals. The cook said that the home was able to provide special diets such as meals for diabetics. Lunch on the day of the inspection consisted of a choice of chicken and mushroom pie, or lamb chop, with croquette potatoes, carrots and broccoli, followed by rice pudding, fresh fruit or yoghurt. Salads and vegetarian options were also available for the main course. Meals served at lunch looked appetising and were well presented. All service users spoken with during lunch said that their meal was good, with one saying that the ‘food was always good’. Staff were seen to assist those service users requiring help, in a friendly, respectful manner. The kitchen looked clean and in good order, with food stored appropriately and the temperatures of fridges and freezers monitored and recorded. Addenbrooke Care Home DS0000039545.V294073.R01.S.doc Version 5.1 Page 15 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 and 18 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to the service. Service users and their relatives know any complaints will be taken seriously and acted upon and they are protected by staff awareness of abuse issues. EVIDENCE: The home has a clear complaints policy and procedures in place that states who will investigate and timescales for the process. The procedures also indicate that a complaint can be forwarded to the commission at any time. The complaints log noted that one complaint had been received in the last year and the records indicated that action had been taken quickly to resolve the issue. Two service users who were asked what they would do if they had any complaints or concerns said that they would talk to one of the staff members. Both said that they did not have any concerns or complaints to report. A relative also said that they knew about the complaints procedures and felt that any concerns raised would be dealt with quickly. Procedures, including Hampshire County Council’s Protection of Vulnerable Adults and Whistle Blowing, are in place for staff to follow should abuse be suspected. Abuse awareness is included briefly, in the induction programme for new staff members. Eleven of the twenty- seven care staff members have attended specific training in the protection of abuse. The registered manager said that arrangements would be made for all remaining staff to receive training. Three staff members spoken with knew about the procedures for Addenbrooke Care Home DS0000039545.V294073.R01.S.doc Version 5.1 Page 16 suspected abuse and said that they would report any concerns immediately to the manager or person in charge at the time of the incident. Addenbrooke Care Home DS0000039545.V294073.R01.S.doc Version 5.1 Page 17 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, 21, 22, 23, 24, 25 and 26 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to the service. Addenbrooke provides a safe, clean and comfortable environment for all who live and visit there. EVIDENCE: The home provides accommodation for thirty-five service users in single rooms. Accommodation is on two floors, with a passenger lift and stairs providing access to each level. The rooms are divided into four units, each having a number of bedrooms, lounge and dining area with kitchenette, bathroom and toilet facilities. There is also a large lounge on the ground floor that is used for activities and group events. Service users bedrooms looked homely and contained many personal items. A service user in her room during the inspection visit said that she liked her room very much. All service users rooms are fitted with a wash hand basin. Addenbrooke Care Home DS0000039545.V294073.R01.S.doc Version 5.1 Page 18 Bathroom and toilet facilities looked clean on the day of the inspection. Two of the four bathrooms had been refurbished prior to the previous inspection visit. The two remaining bathrooms are still awaiting refurbishment. Staff members said that they would like one of the bathrooms to be changed to a wet room with shower as some service users preferred to shower. Assisted baths and overhead hoists were available to assist staff in supporting service users with poor mobility. Specialist equipment such as hoists was also available to assist service users with poor mobility and ramps and grab rails had been fitted to promote and maintain independence. A call alarm system is fitted throughout the home and during the inspection visit call alarms were seen to be available for service users. During the tour of the home some wiring was seen hanging down from the ceiling on one of the units. The assistant manager tied the wiring up so that it was out of reach of the service users and notified Hampshire County Council’s maintenance department who are responsible for maintaining the home. On the second visit the wiring was still tied up, out of reach of service users. The registered manager said that the wiring was to do with the refurbishment of the bathrooms and was not electrical. Arrangements were in place for the wiring to be removed. The home has pleasant gardens that are accessible to service users. Seating is provided. All visitors to the home are required to speak to a member of staff and sign the visitors book on entering and leaving the property to ensure staff are aware of who is in the home at any time. Following an incident where a service user left the home by walking out of the door when it was opened for visitors to leave, a system has been introduced where one door allows access to the reception area and then another door has to be operated to leave the building. This minimises the risk of a service user leaving the home without staff being aware. Addenbrooke Care Home DS0000039545.V294073.R01.S.doc Version 5.1 Page 19 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): Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to the service. Staff are supported and encouraged to attend training sessions to ensure they are able to support the service users. However service users could be put at risk by the lack of staff at times. It was not possible to assess the home’s recruitment procedures have been put into practice, as no new staff members have been employed since the last inspection. EVIDENCE: Rotas seen indicate that four carer staff members and an assistant unit manager are on duty in the morning, the same number in the afternoon and evening and at night there are two care staff and a night co-ordinator. The rota stated that the registered manager was to work flexible hours for the week of the inspection visit. However the registered manager was actually on annual leave, therefore the rota did not reflect the staff that were on duty. The staffing levels allow for one care staff member for each unit on the daytime shifts. This means that when a service user needs assistance that requires two staff members, a unit is left without a carer for the duration of the procedure. During the inspection, while lunch was brought to a unit in a heated trolley, it was observed that the carer was called away from their unit and the inspector noted that service users were left alone for twenty minutes. During this time the service users were making their way to the dining area, some Addenbrooke Care Home DS0000039545.V294073.R01.S.doc Version 5.1 Page 20 with walking frames. A visitor also commented on the times when there were no staff members available on a unit, saying that at times this had been up to thirty minutes. It was observed that when some service users were waiting for their lunch, one became a little anxious and was being calmed down by another service user. On the second visit to the home five care staff members were on duty and a support worker responsible for the activities programme. The registered manager must review the staffing levels to ensure cover is available at all times for service users, taking into account their assessed care needs and their dependency levels. The home keeps a training matrix so that staff training completed is easily recorded. Records seen indicated that thirteen of the twenty seven care staff members hold National Vocational Qualifications, (NVQ), level 2 or above. All staff have received training in moving and handling and all except five had completed food hygiene sessions. Ten carers had attended training in dementia care, together with the registered manager, the assistant unit managers and the night co-ordinators. The assistant unit managers and sixteen carers had also received first aid training. As previously stated in standard 18, the registered manager was arranging for all staff who had not received training in the prevention of abuse to attend training sessions. Two staff members spoken with said that they were encouraged and supported by the registered manager to attend training sessions. At the time of the first inspection visit it was not possible to access staff recruitment records. This was undertaken on the second visit. Recruitment records were seen for three staff members. Records contained all the information required although one did not contain a photograph of the staff member. The registered manager showed the inspector a photograph of the person held in a separate file. A requirement has twice been issued for Criminal Records Bureau and Protection of Vulnerable Adult checks to be completed before staff members commence work at the home. However no staff member has been appointed since the requirements were issued and therefore the home has been unable to confirm that it is meeting the required standard. A further requirement has not been issued. The registered manager stated that the checks were being completed for a prospective employee who had applied for a position at the home and that the person would not commence work at the home until the checks were in place. Addenbrooke Care Home DS0000039545.V294073.R01.S.doc Version 5.1 Page 21 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, 32, 33, 35, 36 and 38 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to the service. Service users benefit from the open approach to management and are protected by being supported by staff who receive regular supervision. However service users safety could be put at risk by the lack of fire drill attendance for some staff members. EVIDENCE: The registered manager, Sue Webber, has the experience and qualifications to run the home and is supported by her line manager. Staff members, service users and a visitor said that Sue Webber was approachable and easy to talk with. During the second inspection visit when Sue was present, service users were observed talking to her in a relaxed manner. The home had recently asked service users relatives or representatives to complete a survey, in the form of a questionnaire, to obtain feedback on the Addenbrooke Care Home DS0000039545.V294073.R01.S.doc Version 5.1 Page 22 quality of care provided at the home. This survey was just beginning and there was no information available at the time of the inspection. However feedback from a relative spoken with indicated that she found the care provided good and there were no issues other than the shortage of staff on units at times. Staff meetings were held on a two monthly basis. Records were kept of the meetings and those seen indicated that all aspects of care provision were discussed. The home keeps small amounts of money for service users. The monies are kept in individual containers in a secure place. Receipts are kept for all transactions and records seen for two service users matched the money held. Relatives who provide money for service users are issued with a receipt that is signed by a staff member and the relative. Staff receive regular supervision. The registered manager provides supervision for the assistant unit managers and night co-ordinators, who in turn supervise the care staff. Records are kept for all supervision meetings Fire records seen indicated that nine staff members had not attended a fire drill in the last year. The assistant unit manager said that a new system for fire safety had been installed recently and this could account for the lack of recording of staff attendance at fire drills. A requirement has been made for all staff members to attend fire drills and for records to be kept up to date and available at the home at all times. Records seen for specialist equipment such as hoists, indicated that regular checks were carried out to ensure equipment was in a good condition. During a tour of the home it was noted that hazardous substances such as cleaning fluids were stored securely. Addenbrooke Care Home DS0000039545.V294073.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 x 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 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 2 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 x 3 3 x 2 Addenbrooke Care Home DS0000039545.V294073.R01.S.doc Version 5.1 Page 24 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. 1. Standard OP27 Regulation 18(1) Requirement The registered person must review staffing levels to ensure that a sufficient number of staff are on duty at all times. The registered person must ensure that all staff attend fire drills and that records of attendance be kept up to date and available at the home at all times. Timescale for action 31/07/06 1. OP38 23(4)(e) 31/07/06 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 OP9 Good Practice Recommendations Medication room be moved to a more suitable room with hand washing facilities. 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