Inspection on 05/09/05 for Adderley House

This inspection was carried out on 5th 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.

Other inspections for this house

Adderley House 15/10/08

Adderley House 10/05/06

Adderley House 30/01/06

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 Toby Payne Unannounced 5 September 2005 9:00 am 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 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 C53 C04 S2315 Adderley House V246575 050905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Adderley House Address 23 London Road Long Sutton Lincs PE12 9EA 01406 364918 01406 363981 Telephone number Fax number Email 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 Sandra Portass Care Home PC only 40 Category(ies) of Old age (40) registration, with number of places Adderley House C53 C04 S2315 Adderley House V246575 050905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: N/A Date of last inspection 4th March 2005 Brief Description of the Service: iAdderley 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 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. The home is registered to provide personal care for up to 40 people over the age of 65 years. 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 C53 C04 S2315 Adderley House V246575 050905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection and started at 9.00 a.m. It took place over 6 hours. The inspector spoke to 12 residents, 3 visitors, 3 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. A pre-inspection questionnaire was completed by the home. The inspector also examined comment cards 19 from residents and 5 from relatives. There were no major concerns. Specific comments were “In my opinion a very caring home under the supervision of Mrs Sandra Portass”, “on the whole I am satisfied with the care given and the level of cleanliness whenever I visit” and “the home treats my relative well, the staff are friendly but more time is needed to talk to the elderly”. What the service does well: What has improved since the last inspection? What they could do better: The owner and manager must address outstanding requirements from previous inspections. The owner must address the outstanding issues of providing an up to date statement of purpose, service user’s guide, complaints procedure, care planning and quality assurance systems. Adderley House C53 C04 S2315 Adderley House V246575 050905 Stage 4.doc Version 1.40 Page 6 The manager needs to confirm in writing to each resident that the home can meet their assessed needs before their admission to the home. The manager needs to introduce a written induction programme for new staff including abuse prevention. 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 C53 C04 S2315 Adderley House V246575 050905 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Adderley House C53 C04 S2315 Adderley House V246575 050905 Stage 4.doc Version 1.40 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 standard(s) 1 and 3 Little progress has been made on producing information to enable residents to make a choice as to whether or not to enter the home. 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: There is still no up to date statement of purpose and service user’s guide. These are outstanding from previous inspections. There is a comprehensive admission procedure, which identifies the needs of residents coming into the home. However, residents do not receive written confirmation that the home can meet their assessed needs. Each resident receives a detailed contract/terms and conditions when moving into the home. Adderley House C53 C04 S2315 Adderley House V246575 050905 Stage 4.doc Version 1.40 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 standard(s) 7, 8 and 10 There has been little improvement with the care planning system in this 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 described 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 incomplete and care records needed to be more detailed with the involvement of the residents. Residents said that staff respected their privacy and dignity. Staff were seen to speak to residents in a calm and polite manner and handle a number frail residents in a gentle manner. Staff were also seen to knock on doors before entering. Adderley House C53 C04 S2315 Adderley House V246575 050905 Stage 4.doc Version 1.40 Page 10 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 standard(s) 12, 13 and 15 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. Visitors are made to feel welcome and supported. EVIDENCE: Activities are displayed on the notice boards in the entrance to the home and the entrance to the flats. The home recently had a very successful summer fayre. 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, “the food is smashing” and “superb”. Although there is a set menu, an alternative can be made available. Two visitors commented, “I can visit whenever I wish and am always made to feel welcome whenever I visit the home”. Adderley House C53 C04 S2315 Adderley House V246575 050905 Stage 4.doc Version 1.40 Page 11 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 standard(s) 16 Any complaints received are handled properly and residents know that any complaints they have will be listened to and taken seriously. EVIDENCE: There has been no action on improving the information in the complaints procedure. Details refer to outdated laws. 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. Adderley House C53 C04 S2315 Adderley House V246575 050905 Stage 4.doc Version 1.40 Page 12 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 standard(s) 19 and 25 Residents live in clean, well decorated and safe accommodation. The gardens are accessible and beautifully maintained. EVIDENCE: Residents who spoke to the inspector said how satisfied they were with 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. There are domestic and laundry staff and residents commented that laundry could be returned on the same day. Comments from residents were “I like my bedroom”, “I have been involved in choosing the colour for my room”, “the home is always clean and tidy” and “my clothes are well laundered”. Adderley House C53 C04 S2315 Adderley House V246575 050905 Stage 4.doc Version 1.40 Page 13 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28 and 30 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: Examination of a staff file of a member of staff who had been recently recruited showed that they had been correctly recruited. Although induction training is provided for new staff there is not a written programme. 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. One resident commented, “staff are always there whenever I need any help”. 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. Adderley House C53 C04 S2315 Adderley House V246575 050905 Stage 4.doc Version 1.40 Page 14 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33 and 37 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 applied to undertake a management qualification. Residents and visitors commented that “I have confidence in the staff and manager”, “I am very satisfied” and “I have no concerns”. Residents, visitors and staff felt they could approach the manager if they had any concerns. Management systems were in place but need more development in order to ensure that they are up to date and reflect current practice. They also need to include quality assurance and audit systems. Adderley House C53 C04 S2315 Adderley House V246575 050905 Stage 4.doc Version 1.40 Page 15 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 1 x 2 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x x x x 3 x STAFFING Standard No Score 27 3 28 3 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x x 3 x 2 x x x 2 x Adderley House C53 C04 S2315 Adderley House V246575 050905 Stage 4.doc Version 1.40 Page 16 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 1 Regulation 4 and 5 Requirement Timescale for action 5/11/2005 2. 3 14(1)(d) 3. 7 15 The owner must produce a statement of purpose and service users guide which is up to date. The terms and conditions agreement must also be in accordance with the National Minimum Standard 2. The statement of purpose must refer to current legislation and be in accordance with Schedule 1 of the Care Homes Regulations 2001. A copy of both documents must be sent to the Commission. A copy of the service user s guide must be given to each resident. The timescale of 29/4/2005 has not been met. The manager must ensure that 5/12/2005 each resident is sent written confirmation that based on the assessment the care home is able to meet their health and welfare needs. The manager must ensure that 5/11/2005 each resident has a detailed care plan which is fully completed, written with the involvement wherever possible of the resident or family and identifies clearly all the persons assessed health and welfare needs. It must be Version 1.40 Page 17 Adderley House C53 C04 S2315 Adderley House V246575 050905 Stage 4.doc 4. 16 22 5. 30 18 6. 33 24 7. 37 Schedule 2 and 3 reviewed wherever possible with the residents involvement. The timescale of 29/4/2005 has not been met. The owner must ensure that 5/11/2005 each resident receives an up to date complaints procedure which includes the address and telephone numbe of the Lincoln office of the CSCI. Any references to the NCSC and Registered Homes Act 1984 must be removed. The timescale of 29/4/2005 has not been met. The manager myust ensure that 5/12/2005 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 consitutes abuse and what staff should do if abuse was suspected. The owner must develop a 5/11/2005 quality assurance system. This should be based on seeking the views of people living in the home, thieir relatives/visitors. In addtion, 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 timescale of 29/4/2005 has not been met. The owner must ensure that all 5/11/2005 policies and procedures are up to date and do not refer to old laws, registering authorities and owners. The timescale of the 29/4/2005 has not been met. Adderley House C53 C04 S2315 Adderley House V246575 050905 Stage 4.doc Version 1.40 Page 18 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 27 Good Practice Recommendations It is 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. It is recommended that the manager monitors the hot water temeratures from hot surfaces and hot water in order to ensure that residents are not put at risk of scalding. Where temperatures exceed 43 degrees Centigrade adjustments should be made. Records should be kept. 2. 38 Adderley House C53 C04 S2315 Adderley House V246575 050905 Stage 4.doc Version 1.40 Page 19 Commission for Social Care Inspection 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 C53 C04 S2315 Adderley House V246575 050905 Stage 4.doc Version 1.40 Page 20 - 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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