Inspection on 10/05/06 for Adderley House

This inspection was carried out on 10th May 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

Adderley House 15/10/08

Adderley House 30/01/06

Adderley House 05/09/05

Adderley House 04/03/05

Adderley House 21/09/04

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

CARE HOMES FOR OLDER PEOPLE Adderley House 23 London Road Long Sutton Lincs PE12 9EA Lead Inspector Mr Toby Payne Unannounced Inspection 10th May 2006 08:30 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 Adderley House DS0000002315.V293873.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. Adderley House DS0000002315.V293873.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Adderley House Address 23 London Road Long Sutton Lincs PE12 9EA 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) 01406 364918 01406 363981 Adderley House Ltd Sandra Denise Portass Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Adderley House DS0000002315.V293873.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th January 2006 Brief Description of the Service: Adderley House Retirement Home is a detached, listed building with a large, purpose built annexe, set in its own grounds and part of a complex, which includes Adderley House Care Home with Nursing. The home is registered to provide personal care for up to 40 people over the age of 65 years. On the day of the inspection there were 37 people living in the home. The home is situated close to the small market town of Long Sutton, which has a range of shops and facilities. The nearest sizeable town is Spalding about 12 miles away. There is accommodation for 14 people in the main building with a further 26 people in 15 self contained flats in an adjoining annexe. Each flat comprises one or two bedrooms, shower or bathroom and kitchenette. The home also provides one day care place. The home changed owners in 2004 and modernising and improving the accommodation continues to take place. The fees at the inspection on the 10/5/2006 ranged from £315 to £422 per week. Extras are for hairdressing, which range from £5 to £17.50p, toiletries and personal newspapers and magazines. Adderley House DS0000002315.V293873.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced and started at 8.30 am. It was undertaken using a review of all the information available to the inspector regarding our service history about Adderley House. It took place over six and a half hours. The inspector spoke to 13 residents, 6 members of staff and the manager. The main method was called “case tracking”. This involved selecting two residents and tracking the care they received through the checking of records, discussion with them, the care staff and observation of how staff responded to their needs and that of the other residents. Prior to the inspection, a pre-inspection questionnaire had been completed by the home and sent to CSCI. Information was used when planning the inspection. Comment cards were received from 14 residents. What the service does well: What has improved since the last inspection? What they could do better: The manager must ensure that all staff have knowledge about how to recognise adult abuse and what they should do if this occurs. Adderley House DS0000002315.V293873.R01.S.doc Version 5.1 Page 6 The owner must address the heating and old water systems in the flats in the annexe as it has been acknowledged that parts are 30 years old. The manager is urged to carry out a survey of the residents to obtain their views about the type and variety of social activities provided. 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. Adderley House DS0000002315.V293873.R01.S.doc Version 5.1 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 Adderley House DS0000002315.V293873.R01.S.doc Version 5.1 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): 1, 2 and 6 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. Progress has been made on producing information to enable residents to make a choice as to whether or not to enter the home. There is now a statement of purpose and service user’s guide. Adderley House Care Home meets the needs of residents coming into the home. People receive an assessment, which results in their assessed needs being met. EVIDENCE: Since the last inspection a detailed service user’s guide has been produced and a clearly written statement of purpose has been produced a copy of which, is available for examination in the entrance to the main building. The service user’s guide is now contained in a large print “welcome pack” which has been placed in each bedroom and describes all the services provided by the home. Each person receives a contract outlining their terms and conditions when being admitted to the home. Adderley House DS0000002315.V293873.R01.S.doc Version 5.1 Page 9 There is a comprehensive admission procedure, which identifies the needs of residents coming into the home. Since the last inspection all residents now receive written confirmation that the home can meet their assessed needs. Prior to admission all residents receive an assessment, which involves the resident, their relative/family and other relevant people. The home does not provide intermediate care. Adderley House DS0000002315.V293873.R01.S.doc Version 5.1 Page 10 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. This judgement has been made using the available evidence including a visit to this service. Since the last inspection there has been improvement with the care planning system in this home. A new more detailed system has been introduced. The health and welfare needs of people living in the home are fully met. Medication is safely administered. People’s privacy are met. EVIDENCE: New more detailed care plans and records were being introduced. These now showed more information about the resident’s health and welfare needs. Records outlined their assessment needs, personal needs, doctor’s notes, care plan, hygiene, nutrition, social activities, mobility and risk assessment, and moving and handling and daily record. Information was now clearer and gave more information to staff concerning how they were to care and support residents. This however, continues to require more refinement but has improved since the last inspection. The home has a medication policy and have received training on this subject. maintained. The home last received a Comments were “storage is good” and Adderley House medication is administered by staff who Records examined were seen to be well pharmacy inspection in December 2005. “stock levels are good”. Version 5.1 Page 11 DS0000002315.V293873.R01.S.doc Residents commented, “Staff are very polite and kind”, “whenever they come and see me they knock on the door before entering my room” and “if I need help the staff are there”. Staff were also seen to be talking and attending to residents in a calm, sensitive manner. Adderley House DS0000002315.V293873.R01.S.doc Version 5.1 Page 12 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 adequate. This judgement has been made using the available evidence including a visit to this service. Social activities are well organised but may not be what many of he residents want. This has provided stimulation and interest for people living in this home. Meals provided are nutritious, balanced and offer a healthy and varied diet. EVIDENCE: Details about activities are displayed on the notice boards in the entrance to the home and the entrance to the flats. Comment cards from 14 residents showed that 6 did not wish to join in activities and only 4 always joined in activities. It is therefore recommended that the views of residents are obtained concerning the type of activities they wish to see. Residents have access to very well maintained extensive safe garden areas and patio area with chairs and tables over looking the gardens. Residents said they enjoyed the food. Comments, were, “I have had an enjoyable breakfast” and “the food is very good”. Although there is a set menu, an alternative can be made available. Residents have control over their lives. Residents commented, “I can do what I like”, “I can get up when I like”, “ like to be as independent as I can, this I can do here” and “staff are very kind and helpful”. Adderley House DS0000002315.V293873.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. Any complaints received are handled properly and residents know that any complaints they have will be listened to and taken seriously. Not all staff have received training to recognise abuse. This could put residents at risk. EVIDENCE: Each resident receives a complaints procedure, when they are admitted to the home. This is now in a “welcome pack”. No complaints have been received by the home or CSCI since the last inspection. None of the residents or visitors had any complaints about the home and felt they could discuss any concerns with the staff or the manager. Staff also knew what to do if they received a complaint from a resident. The home has an adult protection policy but not all staff have received training on this subject although this is now covered during their induction to the home. One member of staff knew what constituted abuse and what they should do if abuse was suspected but another member did not know and acknowledged they had not received this training. Adderley House DS0000002315.V293873.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 25 and 26 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. Residents live in clean, well decorated and safe accommodation. However it has been acknowledged that the water and heating system needs to be renewed in the flats in the annexe. The gardens are accessible and beautifully maintained. . EVIDENCE: Residents said they liked the decoration and cleanliness of the home. They all spoke of how they liked their bedrooms. They also liked and were enjoying the attractive, colourful, accessible garden and patio areas. Residents commented, “my room is beautiful”, “I have very nice room” and “my clothes are looked after well”. However, a number of residents living in the flats in the annexe commented that warm water came out of the cold water taps. This issue was acknowledged by the manager who explained that the owners were keen to address this problem, which had been caused by the age of the system. It was also noted that on the ground floor of a number of flats in the annexe there were wooden ramps resting against the wall of the narrow corridor which would be used to allow access from these flats for people who were becoming more disabled. Adderley House DS0000002315.V293873.R01.S.doc Version 5.1 Page 15 Maintenance and improvement to the facilities in the home continues and on the day of the inspection a new large water tank was being installed in the main house. All bedrooms had radiators and valves to control the hot water temperatures. Temperatures were monitored every month and records showed they were within safe temperatures. The home had infection control and hygiene policies. Gloves and aprons were provided for staff. The home was clean and odour free. The 14 comment cards received and comments made by residents confirmed this. Adderley House DS0000002315.V293873.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. There was a well trained and competent staff team. The numbers of staff were sufficient to meet the needs of the residents. Staff were correctly recruited. EVIDENCE: Separate staff are employed for care, catering, cleaning/laundry and gardening/maintenance. Since the last inspection a new very comprehensive induction programme has been introduced for all new staff. On the day of the inspection a new member of staff was on her first day, following this induction programme, supported and supervised by a senior member of staff. There were comprehensive policies and procedures, which included recruitment and equal opportunities. Records showed staff have been correctly recruited. None of the residents expressed any worries about the level or availability of staff. During the inspection staff were seen to attend to residents promptly. Residents commented, “I like it here”, I am very satisfied”, “fantastic”, “and the staff are very good here”. Staff also felt they had sufficient time to care and support the residents. Comments were “I can make time to spend time with the residents” and 2it is a lovely place to work”. Adderley House DS0000002315.V293873.R01.S.doc Version 5.1 Page 17 There is an extensive training programme for staff, which includes training in care (National Vocational Qualifications), internal lectures and training from outside trainers. The manager has also arranged for further NVQ training to be provided for staff. Over 50 of care staff have achieved or are working towards a qualification in care. Adderley House DS0000002315.V293873.R01.S.doc Version 5.1 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is adequate. This judgement has been made using the available evidence including a visit to this service. The home is lead by an experienced and committed manager. This has lead to a confident, supported and trained staff team. People living in the home are confident in the staff and management of the home and are consulted about changes. EVIDENCE: The manager has worked in the home for 12 years and has been the manager since 2003. Since the last inspection she has started to benefit from attending regular business training. This is in preparation for working towards a management and care qualification. Comment cards received stated, “I am happy here and I get on very well with the staff”, “I am happy here”, “Everything is fine at this home” and “I am quite satisfied with being here”. Adderley House DS0000002315.V293873.R01.S.doc Version 5.1 Page 19 Residents commented, that “ I have no complaints”, the staff attend to me very well”, “I am very satisfied” and “I have no concerns”. Residents and staff felt they could approach the manager if they had any concerns. Staff commented, “staff are very approachable and supportive”, “I feel valued” and “I have seen an improvement in a person I have been spending time with”. Since the last inspection, the issue of quality assurance is being addressed. A survey is to be carried out of resident’s views in the future. Records were kept of resident’s monies with their permission. Receipts were available and kept on their individual files. The manager checked them every month. Formal supervision and appraisal is to be introduced in the future. There were detailed policies and procedures. The home had comprehensive health and safety polices and where required these also included risk assessments. Adderley House DS0000002315.V293873.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 x 3 x x N/A 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 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 3 x x x x x 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 3 x 3 x x 3 Adderley House DS0000002315.V293873.R01.S.doc Version 5.1 Page 21 No Are there any outstanding requirements from the last inspection? 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 OP18 Regulation 13(6) Requirement Timescale for action 10/07/06 2. OP25 23(2)(a) 23(2)(p) The manager must ensure that training is provided for all staff to prevent residents being harmed or suffering abuse or being placed at risk of harm or abuse. The owner is required to ensure 10/07/06 that hot and cold water is provided to all wash basins, baths and showers that residents have access to in the flats in the annexe. Adderley House DS0000002315.V293873.R01.S.doc Version 5.1 Page 22 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 OP12 Good Practice Recommendations It is recommended that the manager carry out a survey of residents to obtain their views regarding the type and amount of activities provided by the home. It is recommended that the owner review the temporary ramps and methods used to enable disabled people to access the ground floor corridor in the annexe. This to ensure that people can safely use the corridor from their accommodation. It is recommended that the manager ensures that each member of staff is given a copy of the General Social Care Council’s Code of Practice and made aware of what its purpose is. 2. OP22 3 OP29 Adderley House DS0000002315.V293873.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Adderley House DS0000002315.V293873.R01.S.doc Version 5.1 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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