Inspection on 30/01/06 for Adderley House

This inspection was carried out on 30th January 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Adderley House 15/10/08

Adderley House 10/05/06

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 30th January 2006 09:00 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 Adderley House DS0000002315.V279500.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.V279500.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.V279500.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th September 2005 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 changes are taking place. Adderley House DS0000002315.V279500.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection and started at 8.45 a.m. It took place over 7 hours. The inspector spoke to 10 residents, one community nurse, 5 staff and the manager. The main method of the inspection was called “case tracking”. This involved selecting 2 residents and tracking the care they received through the checking of records, discussion with them and the care staff. The inspector also observed how care was delivered and how staff responded to other residents living in the home. Comment cards were received from one resident and one visitor. There were no specific comments but no concerns raised. What the service does well: What has improved since the last inspection? What they could do better: Once again, the owner and manager must address outstanding legal requirements from previous inspections. Agreed timescales have not been met and the Commission has been given no reason why these could not be met. The owner must yet again address the issues still outstanding of providing an up to date service users guide and quality assurance system. Adderley House DS0000002315.V279500.R01.S.doc Version 5.1 Page 6 The manager must not admit any new person to the home without confirming in writing to each person that the home can meet their assessed needs before admission to the home. The manager must ensure that each person has an up to date care plan outlining how staff are to deliver the care and support to the person. The manager must also introduce a written induction programme for new members of staff to include abuse prevention and a system to enable each member of staff to receive supervision. 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.V279500.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.V279500.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, 3, 4, 5 and 6 Some 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 but no 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 clearly written statement of purpose has been produced a copy of which, is available for examination in the entrance to the main building. There is however still no service user’s guide. This is outstanding from previous inspections. Each person receives a contract outlining their terms and conditions when being admitted to the home. There is a comprehensive admission procedure, which identifies the needs of residents coming into the home. However, residents still do not receive written confirmation that the home can meet their assessed needs. This is outstanding from the previous inspection. Adderley House DS0000002315.V279500.R01.S.doc Version 5.1 Page 9 Prior to admission all residents receive an assessment, which involves the resident, their relative/family and other relevant people. Residents are invited to stay for the day in order to meet other residents and appreciate the facilities. There is an opportunity of staying for a 2 week trial. The home does not provide intermediate care. Adderley House DS0000002315.V279500.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, 10 and 11 There has been little improvement with the care planning system in this home. This could affect the care of residents in the home. However, despite this the health and welfare needs of people living in the home are fully met. EVIDENCE: All residents had care plans. These gave information about their health and welfare needs. Records outlined assessment needs, personal needs, doctor’s notes, care plan, hygiene, nutrition, social activities, mobility and risk assessment, moving and handling and daily record. However information was still incomplete as there was no information concerning how staff were to care and support residents and there was no evidence that they had been produced with the involvement of the residents. This is still outstanding from the previous inspection. A visiting community nurse expressed satisfaction with the care being provided and the communication between the home and her service. The home has a medication policy and medication is administered by staff who have received training on this subject. Records examined were seen to be well maintained. Adderley House DS0000002315.V279500.R01.S.doc Version 5.1 Page 11 The home has a policy on the subject of death and dying and a number of staff have received training from a local undertaker. Residents, their families and the staff are given support at this sensitive time. Adderley House DS0000002315.V279500.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 and 14 Social activities are well organised. 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. 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 like to be as independent as I can, this I can do here” and “If I need any assistance I only have to ask”. Adderley House DS0000002315.V279500.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): 16,17 and 18 Any complaints received are handled properly and residents know that any complaints they have will be listened to and taken seriously EVIDENCE: Since the last inspection efforts have been made to improve the information in the complaints procedure. Each resident receives a complaints procedure, when they are admitted to the home. 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. Residents are offered support and information to enable them to vote at elections. The home has an adult protection policy but staff do not receive training on this subject at time of their induction to the home. Staff do not receive routine training on this subject. This is outstanding from the previous inspection. Adderley House DS0000002315.V279500.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, 20, 21, 22, 23, 24 and 26 Residents live in clean, well decorated and safe accommodation. 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. There are also attractive, colourful, accessible garden and patio areas. Residents commented, “I like my bedroom”, “I am so warm and comfortable” and “my clothes are looked after well”. There are lounge and dining areas in the home, which were comfortable and well maintained. The main building had 2 bathrooms and 7 toilets (including a staff toilet). The self contained flats contained 13 showers, 2 bathrooms and 15 toilets. The home also had one mobile hoist and fixed bath hoist. Adderley House DS0000002315.V279500.R01.S.doc Version 5.1 Page 15 Resident’s bedrooms reflected their individuality with small items of furniture, television, pictures and personal mementoes. 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. Adderley House DS0000002315.V279500.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 and 29 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. Although induction training is provided for new staff there is not a written programme. This is outstanding from the previous inspection. There were new comprehensive policies and procedures, which included recruitment and equal opportunities. 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, “everyone is so good and kind”, “I love it here” and “the staff are very friendly”. Staff also felt they had sufficient time to care and support the residents. There is an extensive training programme for staff, which includes 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 working towards a qualification in care. Adderley House DS0000002315.V279500.R01.S.doc Version 5.1 Page 17 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, 34, 35, 36 and 38 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. She has not yet started working towards a management and care qualification. This has been a requirement since the 31/12/2005. Residents commented, that “I have confidence in the staff and manager”, “I am very satisfied” and “I have no concerns”. Residents and staff felt they could approach the manager if they had any concerns. Management systems had improved since the last inspection. They still need to include quality assurance and audit systems. These are still outstanding from the previous inspection. Adderley House DS0000002315.V279500.R01.S.doc Version 5.1 Page 18 Records were kept of resident’s monies with their permission. Receipts were available and kept on their individual files. There were detailed policies and procedures. Staff however, were still not receiving formal staff supervision. The home had comprehensive health and safety polices and where required these also included risk assessments. Adderley House DS0000002315.V279500.R01.S.doc Version 5.1 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 2 3 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 2 3 3 3 3 3 3 x 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 3 x x 3 2 x 3 Adderley House DS0000002315.V279500.R01.S.doc Version 5.1 Page 20 Yes 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 OP1 Regulation 4 and 5 Requirement Timescale for action 10/03/06 2. OP3 14(1)(d) 3. OP7 15 The owner must produce a service users guide, which is up to date. A copy of the statement of purpose and service user’s guide must be sent to the Commission. A copy of the service user s guide must be given to each resident. The timescales of 29/4/2005 and 5/1/2005 have not been met. The manager must ensure that 10/03/06 residents are sent written confirmation that based on their assessment the care home is able to meet their health and welfare needs. The timescale of the 05/12/05 has not been met. 30/05/06 The manager must ensure that each resident has a detailed care plan, which is fully completed, written with the involvement wherever possible of the resident or their family and identifies clearly how staff are to carry out all the persons assessed health and welfare needs. It must also where required include a risk assessment and be reviewed wherever possible with the residents involvement. The DS0000002315.V279500.R01.S.doc Version 5.1 Adderley House Page 21 4. OP30 18 5 OP31 9(2)(i) 6. OP33 24 7 OP36 18 timescales of 29/4/2005 and 05/11/05 have not been met. The manager must ensure that all staff receive a written induction programme which includes principles of care, safe working practices, their role within the organisation and the needs of the people living in the home. This also to include what constitutes abuse and what staff should do if abuse was suspected. The timescale of the 05/12/05 has not been met. The owner must send written proposals to CSCI concerning the arrangements for when the manager will start studying for qualifications in care and management up to NVQ level 4. The owner must develop a quality assurance system. This should be based on seeking the views of people living in the home, their relatives/visitors. In addition, internal audits should be introduced to ensure that the service provided meets the needs and satisfaction of people living in the home and their relatives. The timescales of 29/4/2005 and 05/11/05 have not been met. The manager must ensure that all care staff receive formal supervision 6 times a year. This to include all aspects of practice, the philosophy of care in the home and identify their career development needs. Records should be kept. 30/03/06 30/03/06 30/03/06 30/05/06 Adderley House DS0000002315.V279500.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 OP27 Good Practice Recommendations It is again recommended that the manager obtains a copy of the Residential Forums Care Staffing in Care Homes for Older People. This provides guidance recommended by the Department of Health concerning staff numbers. Adderley House DS0000002315.V279500.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. 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