Inspection on 01/07/09 for Adderley Care Home

This inspection was carried out on 1st July 2009.

CQC found this care home to be providing an Adequate service.

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

Other inspections for this house

Adderley Care Home 13/06/07

Adderley Care Home 06/04/06

Adderley Care Home 10/11/05

Adderley Care Home 09/08/05

Adderley Care Home 02/02/05

Adderley Care Home 10/08/04

Adderley Care Home 29/03/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 24/11/2009.

Key inspection report CARE HOMES FOR OLDER PEOPLE Adderley Care Home Adderley House 23 London Road Long Sutton Lincs PE12 9EA Lead Inspector Alison Jessop Key Unannounced Inspection 1st July 2009 09.00 DS0000002653.V376808.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Adderley Care Home DS0000002653.V376808.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Adderley Care Home DS0000002653.V376808.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Adderley Care Home Address Adderley House 23 London Road Long Sutton Lincs PE12 9EA 01406 364309 01406 364938 star.gate@btconnect.com 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) Adderley House Ltd Mrs Joy Ann Byfield Care Home 72 Category(ies) of Dementia (72), Old age, not falling within any registration, with number other category (72) of places Adderley Care Home DS0000002653.V376808.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home with Nursing - Code N to people of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP Dementia - Code DE The maximum number of people who can be accommodated is: 72 2. Date of last inspection 13th June 2007 Brief Description of the Service: Adderley Care Home provides nursing and personal care for up to 72 people. The home is situated in the small market town of Long Sutton and is part of a complex, which includes a separately registered home providing personal care with some self contained flats in the same grounds. The home is close to shops, banks, post office and other facilities. Accommodation is purpose built with single and double bedrooms on the ground and first floors. There are 66 single bedrooms, 26 which are en-suite with showers and 3 double bedrooms. The first floor is served by stairs and a shaft lift. There are accessible gardens and car parking is available at the front of the home. The philosophy of the home includes encouraging people to exercise their rights to the full, to treat each person as an individual and to respect privacy at all times with the aim to create a warm, caring and friendly atmosphere. The fees at the inspection visit ranged from £360 to £463 each week. Extras are for hairdressing which range from £6 to £18.50, chiropody £10, toiletries, personal newspapers and magazines. Information about the home can be obtained from the manager of the home. The statement of purpose, service Adderley Care Home DS0000002653.V376808.R01.S.doc Version 5.2 Page 5 user’s guide, most recent inspection report and leaflets can be found in display shelving in the entrance to the home. Adderley Care Home DS0000002653.V376808.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This was an unannounced visit and it formed part of a key inspection, focusing on key standards, which have the potential to affect the health, safety and welfare of people who use the service. Throughout this report the terms we and us refer to The Care Quality Commission (CQC). The visit lasted approximately six hours and we took into account previous information held by us including the previous inspection report, their service history and records of any incidents that we had been notified of since the last inspection. Before we made our visit the provider had returned the Annual Quality Assurance Assessment (AQAA). This gave us information about their own assessment of how well they are meeting standards and their plans to improve aspects of the service. However, the information in this document was very brief and did not tell us all we needed to know about the service. We sent out surveys to people before we visited the service but to date none of these have been returned to us. The main method used to carry out the inspection is called case tracking, this includes following the care of a sample of four people through their records and assessing their care. We spoke to 10 people who use the service and saw rooms of those people who said we could and spoke to 5 staff members. The registered manager was present throughout the visit and the general outcomes of the visit were discussed with her. We spent from 9.30am until 11.30am in the sitting/dining room with very vulnerable service users to get an impression of what life was like in the home. We made notes every five minutes on the state of being (mood) of the service users, their interaction with their surrounding and other people including staff and interaction with service users. The inspector notes the best interaction observed. Details of this observation are incorporated in the report. What the service does well: We spoke with ten residents who made positive comments about the care they receive. One person said ‘they look after me well, I don’t have any complaints or grumbles.’ Another person said ‘I’m quite happy, I get nice meals and I have a lovely bedroom.’ We found that people receive the health and personal care they need and the home has a good admission process, which means that people’s needs are assessed to make sure that their needs can be met before moving into the Adderley Care Home DS0000002653.V376808.R01.S.doc Version 5.2 Page 7 home. Care plans provided detailed information about each persons care needs and we saw that they had been reviewed regularly. Feedback about the food was good. People said ‘yes, the meals are very nice, we get lots of choice’, and ‘the food is nice and it’s always nice and hot.’ The environment was clean and homely, no unpleasant odours were detected throughout the visit. What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is Adderley Care Home DS0000002653.V376808.R01.S.doc Version 5.2 Page 8 taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Adderley Care Home DS0000002653.V376808.R01.S.doc Version 5.2 Page 9 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 Adderley Care Home DS0000002653.V376808.R01.S.doc Version 5.2 Page 10 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People’s needs are thoroughly assessed before being accepted into the service, this ensures that their needs can be met. EVIDENCE: There was a visitor’s book available and suggestion box on the wall for comments and suggestions in the reception of the home. There was a statement of purpose and service users guide, which were detailed and gave a lot of information about the home and services provided. We noticed that our new name and address and phone number of our National Contact Centre needed to be added to both documents and the complaints procedure. The manager agreed to do this. The manager told us that each person received a copy of the service users guide. The manager told us that where a person was Adderley Care Home DS0000002653.V376808.R01.S.doc Version 5.2 Page 11 referred to the home she would arrange to meet the person and assess their needs involving them and all involved in their care and support. Through case tracking we looked at records for a person who had recently been admitted to the home. We could see that a detailed pre-admission assessment had taken place. The manager told us however that no one received written confirmation that based on the assessment made at the time of admission, the home could meet all their health and welfare needs. The service does not offer intermediate care. Adderley Care Home DS0000002653.V376808.R01.S.doc Version 5.2 Page 12 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People’s health and personal care needs are monitored and met, however this is not always done safely. Staff do not always demonstrate respect to the people who live in the home by the use of language they use. EVIDENCE: Each person had detailed care records giving details about their care and support. We looked at seven care records in depth. The care plans we looked at provided us with detailed information on the health and social needs of the person. The plans included a photograph of the person. Care records included details of their assessment at the time the person moved into the home, care plan, moving and handling and risk assessment. In addition, there was information about the person including life history, significant dates and life experience, brief details of activities of daily living, medication, records of GP and other professionals, monthly weight, risk and nutritional assessments including likes and dislikes. The amount of information was detailed and had Adderley Care Home DS0000002653.V376808.R01.S.doc Version 5.2 Page 13 clear instructions about how staff could meet the needs of the person. The evaluations of the way care had been given were also clearer and entries were signed and dated as were the care plans which showed that the people had wherever possible been involved in their plan of care. The care plans were hand written and detailed their assessed needs and expected outcomes and how the care and support would be provided. We looked seven care records and found only one had a mental capacity assessment completed. We have recommended that this is completed for each person. The manager had introduced a monthly audit to monitor how care records were being recorded. However having looked at the audits we could only see that they had been carried out in January and April 2009. Audits were not taking place monthly. We looked at two food and fluid charts for people where entries had not always been made by staff. One record we saw had a gap of 11.5 hrs where no entry was made. The staff confirmed that fluids had actually been given to the person but this had not been recorded. We looked at records for two people who were cared for in bed and had a fluid balance chart and turning chart which showed the persons position had altered to relieve pressure even though they were on an alternating pressure mattress. We also saw people confined to bed with over bed tables, bed protection rails and drinks within their reach. Where required, people living in the home were referred to GPs, Community Nurse, Community Psychiatric Nurse, Tissue Viability Nurse, Continence Nurse, Physiotherapist, Opticians, Dentist, Chiropodist and other specialists. During the two hour observation of the people who are the most vulnerable, we observed staff carrying out unsafe moving and handling practices. We spoke with the moving and handling trainer at the service who said ‘I am very disappointed to hear this, I have told the staff not to use this method.’ The staff spoken told us that they have received regular moving and handling training. We looked at the moving and handling risk assessments for the people who we observed being moved. One person’s assessment stated ‘use the standing hoist to transfer when she cannot stand.’ On both occasions the standing hoist had not been used and staff were observed lifting people out of the chair manually. Staff had not followed the directions on the care plan and risk assessment. Registered nurses administered medication. There was a policy and procedure for this and the manager told us that she assessed each person before they were considered safe to administer medication. Records we saw were clear and well maintained with a good audit trail. The manager told us that all the people needed a degree of assistance in order to ensure they took their medication safely. The manager had introduced a weekly audit to monitor how records had been maintained. This was last done on the 22/6/2009 and showed adequate records were being kept. Adderley Care Home DS0000002653.V376808.R01.S.doc Version 5.2 Page 14 People we spoke with were satisfied with the way staff cared for them and had confidence in the staff. We saw throughout our inspection staff attended to the people in a warm, friendly and kind manner. We heard staff asking whether they needed any help or whether they could help them. The inspection took place on a very hot sunny day and we saw staff offering frequent cold drinks and jugs of drinks were near them. The people told us, the staff are very nice, we have a lot of laughs and everyone is so kind. Whilst we received some good comments from the resident’s about the staff we also heard some inappropriate use of language used by staff. Staff referred to the unit for people who have dementia as ‘the secure unit’. We pointed out that this is inappropriate as it is the resident’s home. One staff member when asked ‘what is your understanding of good dementia care’ the carer said ‘if they kick off you need to give them your time.’ A resident asked a carer if she could see her husband, the carer abruptly replied ‘your husband is dead, do you want me to get a book so you can read about it?’ Adderley Care Home DS0000002653.V376808.R01.S.doc Version 5.2 Page 15 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Although a programme of activities is available, the most vulnerable people who cannot participate in planned activities are not provided with appropriate stimulation. EVIDENCE: Care records included the life history and backgrounds of the people coming into the home. Activities were briefly referred to in the Service Users Guide and Statement of Purpose. There was an activities person who was responsible for a range of activities which included quizzes and Bingo. During the two hour observation we saw that the residents did not receive any stimulation other than the radio playing and one resident was given a nail manicure. One resident spent the whole time chewing her blouse and moving around in the chair. There was nothing for this person to hold or touch, and staff did not interact with the resident other than when they were providing care. Another resident was handling a small table which kept falling over, the resident was not given anything to occupy themselves with. People do not Adderley Care Home DS0000002653.V376808.R01.S.doc Version 5.2 Page 16 have access freely to the outdoors as there are key codes on the doors although there is a garden to the rear of the building. We saw meals being served in two dining rooms one of which had tables laid with clean table cloths. We saw staff serving food from heated trolleys and sitting by the side of people who needed assistance helping them in a quiet, friendly and calm manner. The people told us I like the food and the food is the way I like it to be. The last inspection by South Holland District council was on the 21/7/2008 which as a result the home was awarded 2 Tulips good in recognition of the catering service provided. The inspection took place on a very hot day and we saw jugs of fruit juice and staff asking people what they wanted to drink. People were assisted to drink regularly and regular snacks were provided. One resident asked for some grapefruit on three occasions, on each occasion the staff brought her a bowl of grapefruit. Residents were given crisps and sweets to snack on throughout the morning. Adderley Care Home DS0000002653.V376808.R01.S.doc Version 5.2 Page 17 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have enough information to enable them to express their concerns and complaints however peoples rights and choices may not be considered. EVIDENCE: There was an up to date complaints procedure in both the Statement of Purpose and Service Users Guide but it did not have a name or contact address and telephone number for CQC. We saw a copy of Lincolnshire County Councils Safeguarding Adults policy and there was a separate policy on adult protection. There was a complaints book with records of three complaints received and action taken by the manager to address them, although the manager had not kept a copy of the response letters to the complainant. We also found that complaints had not been formally acknowledged. One complainant did not visit her husband for several weeks as she was concerned about her own safety after being physically attacked by a resident living in the home. The manager did not acknowledge the complaint or contact the complainant until CQC became involved. This meant that the resident did not receive visits from his wife for several weeks and staff did not discuss this with the resident. When we spoke with the resident he was not aware of the reason his wife had not visited him. Adderley Care Home DS0000002653.V376808.R01.S.doc Version 5.2 Page 18 We spoke with two new members of staff who knew what abuse was and what they should do if abuse was suspected and both confirmed that their induction had covered safeguarding adults. Staff told us they received regular annual refresher training to ensure their knowledge was up to date. We looked at three staff files. These showed a check by the Criminal Records Bureau however we found evidence that employment references had not been gained for new staff from their previous employers (see staffing outcome). None of the people living in the home we spoke with or staff had any complaints about the home and the people felt they could discuss any worries they had with the staff. The service is currently being investigated by the Adult Safeguarding Team as two allegations of neglect have been made. The manager notified CQC of the allegations without delay. The outcome of the investigations will considered by CQC and will be included in the next inspection of this service. Adderley Care Home DS0000002653.V376808.R01.S.doc Version 5.2 Page 19 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides a clean, homely and safe environment to the people who live there. EVIDENCE: People we spoke with were satisfied with the cleanliness and the accommodation in the home. We observed no odours during our visit. We walked around the home and with the permission of the people looked at their bedrooms. We saw there were window restrictors in rooms on the first floor. Rooms we saw were clean, individually decorated with pictures, ornaments and bedding. There were on some doors signs indicating the number of the bedroom and the name of the person. All of the bedrooms had locks to their door. Shared bedrooms had fixed privacy curtains. People throughout our stay Adderley Care Home DS0000002653.V376808.R01.S.doc Version 5.2 Page 20 were dressed in clean clothes which were well maintained and dressed appropriately with in the case of ladies wearing jewellery. The people we spoke with told us I have a very comfortable bedroom, I like my room and my clothes are washed, ironed and returned the next day. There were grab rails and raised toilet seats and a variety of bathrooms containing special disabled access baths one with an over head hoist and shower room and all toilets were wheelchair accessible. There were also thermostatic valves fitted to basins and baths to prevent the people from scalding. There were a variety of pressure relieving mattresses, special profiling beds and a number of mobile hoists with a variety of slings and other moving and handling equipment. There were clear signs throughout the home which showed where toilets, bathrooms and other rooms were. There were garden areas which could be accessed from the lounge areas in the home. The manager told us that they were to receive further developments in the future. Adderley Care Home DS0000002653.V376808.R01.S.doc Version 5.2 Page 21 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is adequately staffed and there is a comprehensive package of training available to staff. The integrity of new staff is not fully checked as employment references are not always verified. EVIDENCE: The people we spoke with felt the home was adequately staffed with staff who were experienced and competent to care for the people living in the home. Comments included, I am very satisfied, the staff have time to spend with me although I know they are very busy and if I need help they come to me quickly and are always kind. The people we spoke with did not express any worries about the level or availability of staff. During our inspection visit we saw staff attended to the needs of the people promptly and in a calm and friendly manner. The home employs registered nurses, care assistants, laundry, administrator, catering staff and an activities co-ordinator. We examined the files for two new members of staff. Records were clear and detailed but one of the records did not show that references had been obtained from their previous employer. Records did show that the process had safely Adderley Care Home DS0000002653.V376808.R01.S.doc Version 5.2 Page 22 included a check by the Criminal Records Bureau (CRB). During the inspection we asked the manager to obtain a reference as soon as possible from the persons last employer and she agreed to do this on the 2/7/2009 and confirmed this with us. When new staff started working at the home they told us they received a supported induction programme during which time they learnt about the policies and procedures of the home and how to provide the necessary care and support to the people there. There continues to be a wide range of training provided. This included formal training in care to National Vocational Qualification standards (82 of the staff had achieved or were studying for NVQ level 2 and 3 staff had achieved NVQ level 3). In addition 6 staff were studying for NVQ level 2 and 6 for NVQ level 3. We saw records and staff confirmed that training over the last year had included, first aid, Mental Capacity Act 2005, food hygiene, infection control, palliative care, tissue viability, and managing challenging behaviour. In addition every year staff are required to have refresher training for adult protection, fire prevention and moving and handling. The home had a training matrix and clear records of training provided. All staff under take a nationally recognised Alzheimer’s awareness course over a period of 10 weeks at the end of which they have an exam by the Alzheimers Society. We saw training manuals about dementia in the home. Staff told us they received regular supervision and an annual appraisal. However despite all the training provided we did not see a great deal of staff involvement with people who had dementia and as a result had difficulty in expressing their views or wishes. We also saw staff using outdated methods being used when handling a person. We spoke with six members of staff who told us we get a lot of training, I have learnt a great deal since I have been here and have gained qualifications and many certificates, I believe we provide good care and am very impressed with the home. Adderley Care Home DS0000002653.V376808.R01.S.doc Version 5.2 Page 23 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Quality systems are ineffective as peoples views are not recorded or acted upon and there is little monitoring of staff adherence to policies and procedures. EVIDENCE: There were many policies and procedures but we noted some had been reviewed in 2008 and others in 2004. These included health and safety, risk assessments, Mental Capacity Act 2005, infection control guidance from the Department of Health. Adderley Care Home DS0000002653.V376808.R01.S.doc Version 5.2 Page 24 Although we could find a quality audit policy in the managers office we could see it last took place in 2007. The manager was unable to tell us when the last survey had taken place to obtain the views of the people in the home. The manager told us that a representative of the company made a weekly visit to the home but although we could see a record of the visit and their findings on the 27/5/2009, the records held showed the next visit was on the 26/8/2008. Reports are required to be made every month. We saw records of the regular servicing of essential equipment and records were on the whole well maintained. There were comprehensive health and safety policies and risk assessments which were last reviewed in October 2008. There was a fire risk assessment and regular tests of the fire system as well as regular fire drills and monthly monitoring of hot water temperatures. Adderley Care Home DS0000002653.V376808.R01.S.doc Version 5.2 Page 25 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Adderley Care Home DS0000002653.V376808.R01.S.doc Version 5.2 Page 26 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 OP3 Regulation 14(d) Requirement Written confirmation must be sent to each person to confirm that having assessed them the service can meet their assessed health and welfare needs. This is to ensure that that the person’s assessed needs can be met. The service user plan and risk assessment must be developed to form the basis of the care to be delivered and staff must work in accordance with this. This is to ensure that people’s needs are safely met and any risks to service users are minimised or eliminated. Staff must refer to and speak to people in a dignified manner. This is to ensure that people are respected. Appropriate stimulation must be provided to everyone living at the home. This is to ensure that the people Adderley Care Home DS0000002653.V376808.R01.S.doc Version 5.2 Page 27 Timescale for action 31/08/09 2 OP7 13 (4)(c) & 13 (5) 31/08/09 3 OP10 12 (4) 31/08/09 4 OP12 16 (n) 31/08/09 5 OP29 19 (1) that may not be able to participate in the planned activity programme receive meaningful stimulation and comfort. People must not be employed to work in the care home until it robust checks have been completed and it has been established that they are of good integrity. This is to protect the people who live in the care home. All staff must receive moving and handling training to ensure that the methods are up to date and cause no harm to themselves or the people being moved. Staff must be monitored to ensure that what is being taught is being used in practice and where this is not taking place additional training or support must be provided. An effective quality assurance system must be maintained for reviewing the quality of services provided. This is to ensure that people are satisfied with the service and to ensure that a good quality service is being provided. Monthly reports must be supplied to the commission. This is to enable the Commission to satisfy itself that the service is being adequately monitored. 31/08/09 6 OP30 13(5) 31/08/09 7 OP33 24 31/08/09 8 OP33 26 (5) 31/08/09 Adderley Care Home DS0000002653.V376808.R01.S.doc Version 5.2 Page 28 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 OP8 Good Practice Recommendations All care plans should include a reference to the Mental Capacity Act 2005 and the effects it has upon people’s lives. This is to ensure that their rights and choices are protected. In addition arrangements should be made for care and nursing staff to receive appropriate training about the assessment and recording of people’s capacity as outlined in this Act. All complaints should be formally acknowledged as described in the company’s complaints procedure. 2 OP16 Adderley Care Home DS0000002653.V376808.R01.S.doc Version 5.2 Page 29 Care Quality Commission East Midlands Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.eastmidlands@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. 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