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Inspection on 12/10/05 for Addison Court Nursing Home

Also see our care home review for Addison Court Nursing Home for more information

This inspection was carried out on 12th October 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Residents described the home as comfortable and homely. During the inspection members of staff were observed speaking to residents in a kind and friendly manner. One lady said, " They treat me like one of the family, they`re all very kind." The daily routine was flexible in order to meet the needs and preferences of the residents. One resident said, " I get up and go to bed when I want." Another resident said, "I can have a lie in if I want one." A range of leisure activities were organised for the residents.

What has improved since the last inspection?

The admission procedure has improved and prospective residents receive confirmation in writing their care needs can be met at the home. Procedures for the safer management and administration of medication have been put in place. Records of medication received into the home were kept and medication was used only for the resident for whom it was prescribed.

What the care home could do better:

At the time of the inspection the home was not being managed properly. Staff morale was very low because their concerns were not being addressed. Staffing levels on the Baxenden unit must be reviewed to ensure enough staff report for duty at 8.00am every morning. Care planning must be improved to ensure all the needs of each resident are met. All care plans must be reviewed monthly and a falls risk assessment completed for each resident. The menus for residents who have difficulty chewing food must be reviewed to ensure they have a well balanced diet. Meals served to residents on the Baxenden unit should be made to look appetising. The whistle blowing policy should be amended to clearly explain the protection available for the whistle blower. This should give members of staff the confidence to report poor practice. The environment on the Baxenden unit and especially in the top floor lounge was unpleasant and must be improved. The odour problem must be addressed. The carpet in the top floor lounge must be cleaned or replaced, the scuffed walls repaired or redecorated, the radiators and the radiator guardsAddison Court Nursing Home DS0000022489.V255020.R01.S.doc Version 5.0 Page 6must be cleaned. The lighting in this room must be improved sufficiently to enable residents to read if they wish. To promote the safety of residents correct moving and handling techniques must be used at all times. Fridge, freezer and food temperatures must be checked and recorded daily. An adequate supply of protective gloves must be provided for use by staff.

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Addison Court Nursing Home Addison Street Accrington Lancashire BB5 6AG Lead Inspector Mrs Susan Hargreaves Unannounced Inspection 10:00 12 and 14 October 2005 th th X10029.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 Addison Court Nursing Home DS0000022489.V255020.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People and Care Homes for Adults 18 – 65*. 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. Addison Court Nursing Home DS0000022489.V255020.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Addison Court Nursing Home Address Addison Street Accrington Lancashire BB5 6AG 01254 233821 01254 393628 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) Speciality Care (Rest Homes) Limited Care Home 50 Category(ies) of Dementia (25), Mental Disorder, excluding registration, with number learning disability or dementia - over 65 years of of places age (25), Old age, not falling within any other category (25), Physical disability (25) Addison Court Nursing Home DS0000022489.V255020.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. Total number of service users within the categories not to exceed 50 (fifty) A maximum of 25 service users requiring nursing care who fall into the category of either OP or PD A maximum of 25 service users requiring personal care who fall into the category of OP A maximum of 25 service users requiring nursing care who fall into either the category of DE or MD(E) A maximum of 10 service users requiring personal care who fall into the category of either DE or MD(E) Staffing for service users requiring nursing care will be in accordance with the Notice issued dated 16 August 2000 20th April 2005 Date of last inspection Brief Description of the Service: Addison Court is a purpose built home situated in a small cul-de-sac in a mainly residential area. It is close to a number of shops and a church. The centre of Accrington is approximately 10 minutes walk away. The home has a small garden, which is accessible to residents who wish to sit outside when the weather permits. There is adequate parking for staff and visitors. Addison Court offers 24 hour nursing and personal care for up to 50 residents. This includes the Baxenden unit, which offers care for up to 25 residents who suffer from mental health problems or dementia. Accommodation is provided in single en-suite rooms. A passenger lift facilitates access to all areas of the home. Addison Court Nursing Home DS0000022489.V255020.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one and a half days and involved two inspectors. At the time of this inspection 49 residents were living at the home. A tour of the premises took place and staff files and care records were inspected. Members of staff on duty, residents and visitors were spoken to. The post of registered manager is vacant but the area manager was present on the second day of the inspection. What the service does well: What has improved since the last inspection? What they could do better: At the time of the inspection the home was not being managed properly. Staff morale was very low because their concerns were not being addressed. Staffing levels on the Baxenden unit must be reviewed to ensure enough staff report for duty at 8.00am every morning. Care planning must be improved to ensure all the needs of each resident are met. All care plans must be reviewed monthly and a falls risk assessment completed for each resident. The menus for residents who have difficulty chewing food must be reviewed to ensure they have a well balanced diet. Meals served to residents on the Baxenden unit should be made to look appetising. The whistle blowing policy should be amended to clearly explain the protection available for the whistle blower. This should give members of staff the confidence to report poor practice. The environment on the Baxenden unit and especially in the top floor lounge was unpleasant and must be improved. The odour problem must be addressed. The carpet in the top floor lounge must be cleaned or replaced, the scuffed walls repaired or redecorated, the radiators and the radiator guards Addison Court Nursing Home DS0000022489.V255020.R01.S.doc Version 5.0 Page 6 must be cleaned. The lighting in this room must be improved sufficiently to enable residents to read if they wish. To promote the safety of residents correct moving and handling techniques must be used at all times. Fridge, freezer and food temperatures must be checked and recorded daily. An adequate supply of protective gloves must be provided for use by staff. 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. Addison Court Nursing Home DS0000022489.V255020.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Addison Court Nursing Home DS0000022489.V255020.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 (Older People) 2 (Adults 18-65) Admission procedures were thorough. A pre-admission assessment was completed for each resident prior to admission. EVIDENCE: Individual records of six residents were inspected. Each contained a preadmission assessment of need. A senior member of staff visited prospective residents in hospital or their own home prior to admission. Prospective residents received confirmation in writing that their needs could be met at the home. The assessment of need provided useful information for the care plan. Addison Court Nursing Home DS0000022489.V255020.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are 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 and 9 (Older People) 6, 19 and 20 (Adults 18-65) A care plan was in place for each resident. Not all care plans included a falls risk assessment. This could potentially put residents at risk. Medication was managed efficiently promoting good health. Addison Court Nursing Home DS0000022489.V255020.R01.S.doc Version 5.0 Page 10 EVIDENCE: The individual care plans of six residents were inspected. These plans identified the personal care needs of each resident and explained how these needs were met. However, not all aspects of health care were addressed. A care plan, which explained how diabetes was treated and controlled for one resident was not in place. A falls risk assessment had not been carried out for two of these residents. Three of the care plans inspected had not been reviewed since August. Residents were registered wit a GP and had access to other healthcare professionals. At the time of the inspection two of the residents were self-medicating with inhalers. Risk assessments for this were included in their individual care records. Registered nurses were responsible for administering all other medication. Records relating to the management of medication were seen to be up to date and included details of medication received into the home and disposed of by a licensed waste carrier. The nurse in charge was advised to provide written instructions stating when medication prescribed ‘when required’ should be given to individual residents. Medication was stored correctly in cupboards, trolleys and a fridge inside a locked utility room. The temperature of these areas was checked and recorded daily. Addison Court Nursing Home DS0000022489.V255020.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the 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 and 15 (Older People) 13 and 17 (Adults 18-65) Social activities were available and visitors were welcomed into the home at anytime. Meals were wholesome but not always suitable for residents who had difficulty chewing. EVIDENCE: The activities co-ordinator was responsible for planning and implementing a range of leisure activities. These included various games, dominoes, movement and music and videos. Residents were encouraged to sit outside in the garden when the weather permitted. Outside entertainers regularly visited the home and special occasions were celebrated e.g. Halloween, Christmas etc. Addison Court Nursing Home DS0000022489.V255020.R01.S.doc Version 5.0 Page 12 Discussion with residents and staff confirmed that visitors were welcomed into the home at anytime. Members of staff working on the Baxenden unit considered the quality of the food to be poor. They explained that the menu wasn’t good for residents who had difficulty chewing. The meat was fatty and when all the fat had been cut off there was hardly anything left. One resident on the Baxenden unit said, “yesterday I had a drop of soup and two sandwiches at dinner time, I was offered ice cream but I didn’t want it. I could have eaten a slice of bread but was told there wasn’t any up.” The meal served at lunchtime on the day of the inspection looked wholesome but did not look as appetising on the Baxenden unit as it did on the general unit. Residents on the general unit said the food was good. Members of staff were observed assisting residents in a patient and sensitive manner. Addison Court Nursing Home DS0000022489.V255020.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) 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 (Older People) 22 and 23 (Adults 18-65) Complaints were taken seriously and investigated. Appropriate procedures and training were in place to ensure the protection of residents at the home. EVIDENCE: A comprehensive complaints procedure was in place. One complaint has been made to the commission since the last inspection. Policies and procedures relating to the protection of vulnerable adults were in place. Members of staff consulted were aware of the procedure and said they would report any concerns immediately. The ‘whistle blowing’ policy was out of date and needed amending to clearly explain the protection available for the ‘whistle blower.’ Addison Court Nursing Home DS0000022489.V255020.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) 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 and 26 (Older People) 24 and 30 (Adults 18-65) The general unit was clean and well maintained providing a pleasant environment for the residents. The Baxenden unit had an unpleasant odour and some areas were in need of cleaning and redecoration. Laundry facilities were appropriate for the size of the home. Addison Court Nursing Home DS0000022489.V255020.R01.S.doc Version 5.0 Page 15 EVIDENCE: At the time of the inspection the general unit was clean, tidy and free from offensive odours. However, there was an unpleasant odour on the Baxenden unit and the top floor. The carpet in the top floor lounge was badly stained, the walls were scuffed in places and the radiator covers and radiators were dirty. In addition to this the lounge was dimly lit and there was condensation between the double-glazing on the windows. This unit did not provide a pleasant environment for the residents. An unused bathroom on the top was used for storing bed rails and wheelchairs. The door to this room was open and potentially dangerous for residents who were inclined to wander. The lock was also broken on a nearby toilet door. This issue was discussed with the nurse in charge and the handyman and by the second day of the inspection star locks had been fitted to these rooms. The area manager was present on the second day of the inspection and explained that arrangements were being made to address the problems identified on the Baxenden unit. Laundry facilities were appropriate for the size of the home. However, the sink was full of clothes and the soap dispenser was empty. This could potentially be an infection control risk. Policies and procedures for the control of infection were in place. Addison Court Nursing Home DS0000022489.V255020.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the 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 (Older People) 34 (Adults 18-65) Staffing levels on the general unit were appropriate to meet the assessed needs of the residents. Between 8.00am and 9.00am staffing levels on the Baxenden unit were not always sufficient to meet the needs of the residents. Training for all members of staff was encouraged. Recruitment procedures were thorough. EVIDENCE: Examination of the duty rota confirmed that staffing levels on the general unit were sufficient to meet the assessed needs of the residents. However, on the day of the inspection on the Baxenden unit only the nurse and one care assistant were on duty between 8.00am and 8.30am and between 8.30am and 9.00am the nurse and two care assistants. At 9.00am a further three care assistants came on duty. The nurse in charge explained this had happened because three members of staff for this unit were allowed to begin their shifts at 9.00am instead of the usual 8.00am when the night staff went off duty. The nurse said this only happened occasionally but often one and sometimes two care assistants were not on duty until 9.00am. This could potentially put Addison Court Nursing Home DS0000022489.V255020.R01.S.doc Version 5.0 Page 17 residents at risk. Several members of staff and a visitor expressed concern about the number of care assistants whose first language wasn’t English. They explained that although these members of staff were good carers there were communication difficulties especially with the residents suffering from dementia. This was particularly difficult when two of these care assistants worked together on the top floor. It was evident from discussions with members of staff that training was encouraged. This included, induction training for new employees, moving and handling, basic food hygiene, dementia and abuse awareness. In addition to this seven care assistants had achieved NVQ level 2 and several others were working towards this qualification. The files of four members of staff appointed since the last inspection were examined. These indicated that all the required pre-employment checks to ensure protection of the residents had been completed. Addison Court Nursing Home DS0000022489.V255020.R01.S.doc Version 5.0 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) 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 (Older People) There is a lack of leadership in the home and staff morale is low. Residents and their relatives were consulted about the quality of the care and services provided at the home. Addison Court Nursing Home DS0000022489.V255020.R01.S.doc Version 5.0 Page 19 EVIDENCE: At the time of the inspection there was a vacancy for a registered manager. Although some managerial support was provided by senior staff from Craegmoor Healthcare this did not give the necessary leadership for the home to be run properly. Staff morale was very low. Members of staff said there was no one to go to if they had concerns and problems were not being addressed. The home had achieved the nationally accredited Investors in People award. An annual development plan was available. Anonymous satisfaction questionnaires were given to a percentage of residents and relatives every month. Policies and procedures were reviewed at head office. Records of transactions involving resident’s money were seen to up to date and accurate. During the inspection members of staff were observed using an inappropriate moving and handling technique. Records of fridge, freezer and food temperatures were not kept. Members of staff expressed concern about the supply of protective gloves. Three care assistants had bought a supply for themselves because they regularly ran out. Safety procedures were displayed in the home. Addison Court Nursing Home DS0000022489.V255020.R01.S.doc Version 5.0 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 X 2 X 3 3 4 X 5 X 6 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 ENVIRONMENT Standard No Score 19 1 20 X 21 X 22 X 23 X 24 X 25 X 26 2 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 1 32 X 33 3 34 X 35 3 36 X 37 X 38 2 Addison Court Nursing Home DS0000022489.V255020.R01.S.doc Version 5.0 Page 21 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 OP7 Regulation 15(1) Requirement Unless it is impracticable to carry out such consultation, the registered person shall, after consultation with the service user, or a representative of his, prepare a written plan as to how the service user’s needs in respect of his health and welfare are to be met. Care plans must address all identified needs. The registered person shall ensure that- (b) any activities in which service users participate are so far as reasonably practicable free from avoidable risks; and (c) unnecessary risks to the health and safety of service users are identified and so far as possible eliminated. All residents must have a falls risk assessment. The registered person shall – (b) keep the service user’s plan under review. All care plans must be reviewed monthly. Timescale of 1/7/05 not met. The registered person shall DS0000022489.V255020.R01.S.doc Timescale for action 02/12/05 1 OP7 13(4)(b)(c) 02/12/05 3 OP7 15(2)(b) 02/12/05 4 OP15 16(2)(i) 02/12/05 Version 5.0 Page 22 Addison Court Nursing Home 5 OP19 6 OP19 7 OP27 having regard to the size of the care home and the number and needs of service users (i) provide in adequate quantities, suitable, wholesome and nutritious food which is varied and properly prepared and available at such time as may be reasonably be required by service users. Meals suitable for residents who have difficulty chewing must be provided. 16(2)(k) The registered person shall having regard to the size of the care home and the number and needs of service users – (k) keep the care home free from offensive odours and make suitable arrangements for the disposal of general and clinical waste. The odour problem on the Baxenden unit and top floor must be addressed. 23(2)(d)(p) The registered person shall having regard to the number and needs of the service users ensure that (d) all parts of the home are kept clean and reasonably decorated. The carpet in the top floor lounge must be cleaned or replaced. The scuffed walls must be repaired or redecorated. The radiators and the radiator guards must be cleaned. (p) ventilation, heating and lighting suitable for service users is provided in all parts of the care home which are used by service users. The lighting in the top floor lounge must be improved sufficiently to enable residents to read if they wish. 18(1)(a) The registered person shall, DS0000022489.V255020.R01.S.doc 02/12/05 30/12/05 02/12/05 Page 23 Addison Court Nursing Home Version 5.0 8 OP31 8(1) (2) 9 OP38 13(5) 10 OP38 13(3) having regard to the size of the care home, the statement of purpose and the number and needs of service users – (a) ensure that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of service users. No more than one care assistant must be on the rota to begin work at 9.00am on any day. The registered provider shall 14/11/05 appoint an individual to manage the care home where – (a) there is no registered manager in respect of the care home and (b) the registered provider – (i) is an organisation or partnership. (2) Where the registered provider appoints a person to manage the care home he shall forthwith give notice to the Commission of (a) the name of the person appointed; and (b) the date on which the appointment is to take effect. Arrangements must be made for the home to be managed effectively until a manager is appointed. The registered person shall 02/12/05 make suitable arrangements to provide a safe system for moving and handling service users. The registered person shall 14/11/05 make suitable arrangements to prevent infection, toxic conditions and the spread of infection at the care home. Fridge, freezer and food temperatures must be checked and recorded daily. An adequate supply of DS0000022489.V255020.R01.S.doc Version 5.0 Page 24 Addison Court Nursing Home protective gloves must be provided for use by staff. 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 2 3 4 5 Refer to Standard OP9 OP15 OP18 OP19 OP27 Good Practice Recommendations Written instructions should be in place for individual residents stating when medication prescribed when required should be given. Meals served on the Baxenden unit should look attractive and appealing to the residents. The whistle bolwing policy needs amending to include details of the protection avialble for the ‘Whistle Blower’. Clothes should not be left in the sink in the laundry. The soap dispenser should be refilled when empty. When there are only two members of staff on duty on the top floor one of them should have English as their first language. Addison Court Nursing Home DS0000022489.V255020.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB 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. Addison Court Nursing Home DS0000022489.V255020.R01.S.doc Version 5.0 Page 26 - 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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