This inspection was carried out on 21st September 2005.
CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.
CARE HOMES FOR OLDER PEOPLE
Addenbrooke Care Home Willis Road Gosport Hampshire PO12 1NA Lead Inspector
Anita Tengnah Unannounced Inspection 21st September 2005 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.V251600.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. Addenbrooke Care Home DS0000039545.V251600.R01.S.doc Version 5.0 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.V251600.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 20/04/05 Brief Description of the Service: Addenbrooke is a registered care home that provides personal care to 35 service users in the older person category. The home is situated in the historic town of Gosport and is close to the waterfront and local amenities. Hampshire County Council operates the service. Accommodation is provided on two floors with a passenger lift in place that allows access to all parts of the home. All the rooms are single and are fitted with wash hand basins. The service benefits from well-maintained and enclosed gardens that are accessible to service users. Addenbrooke Care Home DS0000039545.V251600.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. An unannounced inspection took place over one day on the 21st of September 2005. This was the second inspection undertaken for this year. The inspection lasted over five hours. The inspection process included examining care records, discussion with 8 service users, 7 staff and one visitor. A tour of the premises was also undertaken. What the service does well: What has improved since the last inspection?
There is an ongoing programme of refurbishment in place. Two bathrooms have recently been totally refurbished. These were clean and homely in appearance. Assisted Arjo baths had been fitted and overhead hoist facilities were in place that met the needs of service users. The banisters on the back staircase have been raised as part of the health and safety measures at the service. Staff reported that there have been a reduction in agency staff following a successful recruitment drive that ensure continuity of care for service users. A training matrix has been developed that will help in identifying any shortfall/gaps in staff attendance and is easier to access these records.
Addenbrooke Care Home DS0000039545.V251600.R01.S.doc Version 5.0 Page 6 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. Addenbrooke Care Home DS0000039545.V251600.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 Addenbrooke Care Home DS0000039545.V251600.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 The assessments and reviews of service users admitted for respite care do not reflect that all their needs are assessed. This can be detrimental to the welfare and fall short of meeting all their needs. EVIDENCE: The records of service users that were recently admitted for respite care were seen. The care management assessments were available. However the home’s pre-assessment records were not available. As part of the process, the views of a recently admitted service user and her relative were sought. They said that they were not aware of any care plans as they raised the issue that the service user had been at the home for a week and had not had a bath. The manager must ensure that service users/ advocates have access to care plans and are involved in care planning. They were happy to raise these issues with the staff. Addenbrooke Care Home DS0000039545.V251600.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 Care plans are formulated on admission. However the lack of assessments of all care needs can be detrimental to the welfare of service users. Staff training in the management of medication is good. The lack of record of some medication administered is detrimental to the welfare and safety of service users. EVIDENCE: Arrangements were in place to meet the needs of service users. These included manual handling assessments and some activities of daily livings. Night care needs were assessed and care plans were in place. Records showed that service users admitted for respite care did not contain all the needs assessments such as nutritional, spiritual and cultural needs and falls risk assessments. Care plans were not dated and it was unclear whether needs assessments were reviewed at each admission to reflect any changes in the needs of service users. Evidence of carers/ advocates involvements in the formulation of care plans was not available. This is particularly pertinent as service users suffer from a degree of dementia and may not be able to partake in the assessment process.
Addenbrooke Care Home DS0000039545.V251600.R01.S.doc Version 5.0 Page 10 This was discussed with staff and remedial actions are required in order that the care needs of service users are met. Staff reported that a new care planning system was being introduced soon. It is recommended that training for carers are considered as staff reported that this may be part of the problem as they are not familiar with the care plans. The home has a policy and procedure in place for the management of medication. Training in the administration of medication was available. It was noted that medication cupboard was in an area that was cramped and did not have hand-washing facility. Staff reported that they had difficulty in accessing the shelves as these were high and the cupboard had restricted space for them to move. Discussion had been undertaken previously for an area on the first floor that was vacant and could be refurbished for that purpose. A sample of Medication Administration Record (MAR) sheet as maintained by the home showed that not all medication administered had been recorded on the MAR sheet. The manager must ensure that accurate records of all medication administered are maintained. There was also a large stock of some medication that included creams and aperients. A review of the procedures for ordering and returned of medication should be undertaken. Addenbrooke Care Home DS0000039545.V251600.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): 12,15 The meals at the home are well managed offering choice and variety to service users. The activity programme at the home is good, with dedicated staff responsible for activities. EVIDENCE: The home employs two support workers who are responsible for activities programme for service users. Staff and service users spoken to had positive comments about this service. Service users said that they liked the activities and that it kept them busy. Activities are undertaken in the large communal room on the ground floor where there are facilities for making hot drinks as required. The home has a menu that is rotated on a 4 weekly basis. The kitchen was well organised and clean. The chef said that a review of the winter menu was being undertaken in order that more variety is available. The delivery of food is well organised. Fresh meat is delivered weekly and fresh vegetable and fruits twice weekly. Food was stored in the fridge appropriately and labelled as required.
Addenbrooke Care Home DS0000039545.V251600.R01.S.doc Version 5.0 Page 12 It was noted that dry food is delivered in catering size and are decanted in smaller containers. Discussion was undertaken with the chef to ensure that these are labelled with the expiry dates on transfer to small containers. There is a choice of menu available. Service users are consulted about the menu and cooked breakfast was available on Saturdays. Meals were nicely presented and appeared appetising and well balanced. Hot and cold drinks are available at all times. Staff were observed to be available to offer support with meals in a sensitive manner. Addenbrooke Care Home DS0000039545.V251600.R01.S.doc Version 5.0 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 The complaint and adult protection at this home is well managed ensuring the safety and welfare of service users. EVIDENCE: The home has a complaint policy and procedure in place. A complaint log was maintained. Record shows that there has been no recorded complaint since the last inspection. Information about the complaint procedure was available. The home has a booklet produced by Hampshire County Council regarding making a complaint. Discussion was undertaken with staff as this guidance did not reflect that service users could refer their complaint to the Commission for Social Care Inspection. In order to avoid confusion and to meet the requirements of Regulation 22, the provider must address this issue. There is an adult protection procedure in place including the Hampshire Adult Protection guidance. Staff had undertaken training in adult protection recently. Staff spoken to were aware of the needs to record and report any allegation of abuse. Addenbrooke Care Home DS0000039545.V251600.R01.S.doc Version 5.0 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): 19,21,23 The service provides a warm, safe and homely environment to meet the needs of service users. Service users bedrooms are personalised and suits their needs. EVIDENCE: The home has a warm and homely atmosphere. All parts of the home seen was well maintained. Furnishing was of good quality and appropriate to service users’ needs. Most of the service users rooms were personalised, with lots of items of personal belongings. The home has adequate bathrooms and toilets to meet the needs of service users. Two bathrooms have been completely refurbished since the last inspection. These were bright and clean with assisted baths and electric ceiling
Addenbrooke Care Home DS0000039545.V251600.R01.S.doc Version 5.0 Page 15 hoists. Two service users spoken to said they liked the new baths. The two remaining bathrooms are in need of redecoration. The home has equipment such as hoists, ramps and grab rails were in place to promote and maintain service users independence. Call bells were available in service users bedrooms. The service benefits from well-maintained gardens that are accessible to service users. Seating was provided and sunshades were available. Addenbrooke Care Home DS0000039545.V251600.R01.S.doc Version 5.0 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): 27,29,30 The home has a number of staff with the appropriate skills in delivering a high quality of care. The recruitment process remains inadequate in ensuring the safety of service users. There is a training plan in place that ensures that staff have the skills and knowledge in delivering care safely. However the fire safety records pertaining to staff training were inadequate. EVIDENCE: The home has a duty rota for carers and a separate rota for ancillary workers. The day shift has one carer in each unit who is supported by a senior staff member. Staff reported that there has been a reduction in agency staff following a recent recruitment programme. Positive comments were received about staff from service users and visitors spoken to. The home has changed the night duty rota. Staff reported that there is no longer a sleeping senior staff member on nights. This has been replaced with one night coordinator and one carer. Previously there were two carers and a sleeping in senior member of staff. This has in effect lead to a reduction of night staff. The provider must ensure that there are adequately trained staff and in sufficient numbers to meet the needs of service users. This was discussed with the manager who said that this was under review. Staff also
Addenbrooke Care Home DS0000039545.V251600.R01.S.doc Version 5.0 Page 17 said that the dependency of service users remains high and there is one unit dedicated to respite care. A sample of three staff records was examined as part of the inspection. An induction programme was in place for all new employees at the start of their employment. Staff records contained some records of checks such as CRB and POVA first checks. One carer did not have any record of CRB and POVA first check. Another carer record contained only one reference. Record also showed that one carer started at the service in June o5 and her CRB check was not confirmed until July 05, there was no record of POVA first check available. These have been highlighted at previous inspections. The provider must ensure that all checks are undertaken prior to employment and that staff records are maintained as per Schedule 2. The home has put in place a good induction and training programme for all staff. Staff had undertaken a variety of updates/ training to maintain their skills and included first aid, elder abuse, manual handling and a number of carers have achieved the National Vocational Qualification at level 2. A training matrix has been developed and training data was being updated. This is a very good system and will help identify training needs and records readily accessible. Discussion was undertaken about the fire safety training for all carers. Some staff said that they had attended recent training in fire safety, however the records were not up to date. Addenbrooke Care Home DS0000039545.V251600.R01.S.doc Version 5.0 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): 38 The health and safety practices at the home are well managed. EVIDENCE: The home has in place health and safety information and this is also covered at induction. Following recent renovation, the banisters of the back stairwell have been raised for the safety of service users. The home was well maintained and equipment stored appropriately. The water system was being flushed on the day of the inspection. Fire extinguishers had been serviced at regular intervals as required. The home has an infection control policy in place. All substances hazardous to health were stored safely. Fire drills and fire alarm testing are carried out at regular intervals and records of these were maintained. Addenbrooke Care Home DS0000039545.V251600.R01.S.doc Version 5.0 Page 19 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 2 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x 3 3 x x STAFFING Standard No Score 27 2 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x x x x x x 3 Addenbrooke Care Home DS0000039545.V251600.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? Yes 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 OP3 Regulation 14(1) (a) Requirement The manager must ensure that all needs are assessed and records of these maintained. Pre admission assessments records must be available and form part of care planning. Evidence of service users/ advocate involvement in the formulation of care plans must be maintained. Care plans must be updated to reflect any changes in the needs of service users. The manager must ensure that there is a record of all prescribes medication that is administered to service users. The provider must ensure that there are sufficient numbers on night duty to meet the needs of the service users. (Previous timescale of 30/05/05 not met.) The manager must maintain evidence of all checks undertaken for staff prior to employment. Staff records must be maintained as per schedule 2. (Previous timescale of 30/05/05 not met.)
DS0000039545.V251600.R01.S.doc Timescale for action 30/10/05 2 OP7 15(1) (2) 30/10/05 3 OP9 4 OP27 13(2) 17(1) (a) schedule 3 18(1) 30/10/05 30/10/05 5 OP29 7,9 30/10/05 Addenbrooke Care Home Version 5.0 Page 21 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 Addenbrooke Care Home DS0000039545.V251600.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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