Inspection on 02/02/06 for Adelphi Rest Home

This inspection was carried out on 2nd February 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

Adelphi Rest Home 20/07/06

Adelphi Rest Home 06/09/05

Adelphi Rest Home 25/10/04

Adelphi Rest Home 14/04/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Adelphi Rest Home 33/35 Queens Road Chorley Lancashire PR7 1LA Lead Inspector Della Lovell Unannounced Inspection 2nd February 2006 09:30 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 Adelphi Rest Home DS0000005922.V280960.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. Adelphi Rest Home DS0000005922.V280960.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Adelphi Rest Home Address 33/35 Queens Road Chorley Lancashire PR7 1LA 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) 01257 271361 01257 271361 Mr Barry Brown Mrs Jacqueline Taylor Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places Adelphi Rest Home DS0000005922.V280960.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th September 2005 Brief Description of the Service: The Adelphi Residential Care Home is situated in a quiet residential area within walking distance of both Chorley town centre and Astley Park. The home is well served by public transport and the M62 and M6 motorways are both easily accessible nearby. The accommodation consists of two residential dwellings, which have been converted, along with the addition of an extension, to provide 22 bedrooms, four of which are companion rooms, three lounges and a dining room. Some rooms have en suite facilities, but those, which do not, are fitted with vanity units. Of the homes three lounges, one is a conservatory type lounge and the dining room also extends into a conservatory. All the service users rooms and the communal areas are tastefully decorated and service users are encouraged to personalise their rooms with items brought from home. There is a small courtyard type garden to the rear of the home, which is furnished, through the summer months, with sets of garden furniture. The garden is accessed via the dining room through patio doors, where a ramp is fitted to ease access to and from the garden. Adelphi Rest Home DS0000005922.V280960.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 that took place over one day in February 2006. The inspection involved a lot of discussion with the people that lived and worked at the home and relatives visiting. The inspector examined records and toured the building. What the service does well: What has improved since the last inspection? What they could do better: Although the home is clean and tidy it could do with some refurbishment and redecorating. The inspector noted that the paintwork around doors were Adelphi Rest Home DS0000005922.V280960.R01.S.doc Version 5.1 Page 6 marked and chipped and the dining area walls, which is used as a designated smoking area, were discoloured. The bathrooms on the first floor could also do with refurbishment. The registered person should develop a redecoration and refurbishment programme to ensure that action is taken where needed. 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. Adelphi Rest Home DS0000005922.V280960.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 Adelphi Rest Home DS0000005922.V280960.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): 3 The home had a good assessment procedure, which ensures service users needs are assessed and met. EVIDENCE: Two service users files were looked at. One was a recent admission to the home. Since the last inspection the home had developed a new format for undertaking assessments. The inspector noted that the home had used the new format with regards to the new service user and this assessment provided comprehensive information and details of the service users needs and the service user had been involved in the process. Adelphi Rest Home DS0000005922.V280960.R01.S.doc Version 5.1 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 the following standard(s): 7,8 and 9 Resident’s health and personal care is met by the home’s care planning process. The homes medication procedure ensures the safety of service users. EVIDENCE: Since the last inspection the home had developed a new care planning system, which covered all health, personal and social care needs. The files of two service users were looked at. One service user had recently been admitted to the home. The second service users had lived at the home for seven months but health needs had deteriorated. The combined assessment and care plan covered all the list identified in Standard 2.2 of the National Minimum Standard. There were clear instructions on the care plan for staff on how to met the assessed needs, which included health care needs. There was information on the care plan with regards to specialised mattress for pressure care and intervention from the community nurses. Alongside the care plan there were a number of risk assessments, which took into consideration mobility and the service users individual environment. All care plans had been reviewed. A daily record was kept which recorded the Adelphi Rest Home DS0000005922.V280960.R01.S.doc Version 5.1 Page 10 care given and any significant events. Staff spoken to were fully aware of needs. Policies and procedures for medicines management were in place and reflected current practice. All medication is prepared in blister packs by the local pharmacist. The registered person should ensure that prescriptions are seen by the home before going to the Pharmacist. Medication Administration Record charts were examined and found to be clear and accurate with no gaps. Storage of medication was appropriate, clean and tidy and the trolley was secured when not in use. Stock control appeared to be good, with no excess, discontinued or out of date medication present. The inspector was informed that medication training had been provided to senior staff. Adelphi Rest Home DS0000005922.V280960.R01.S.doc Version 5.1 Page 11 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 and 14 The homes procedures enable residents to exercise choice and control over their lives and contact with family and friends are actively encouraged. EVIDENCE: During the inspection visitors were seen calling in at the home, both service users and relatives were able to confirm that there were no restrictions with regards to visiting. Service users told the inspector that they were able to see their visitors in their own room or the communal areas if they so choose. One relative spoken to said, “I call nearly every day and can visit when I want.” One service user spoken to said, “My family can call when they want”. Service users or their families manage the finances. The home provides a lockable storage area in all the bedrooms and payments are generally made via a relative. The home holds a small amount of money for some service users. All written records were seen maintained and up to date. Observations made confirmed residents had control over their own lives. Breakfast was staggered as service users got up and during the day service users were seen either in their own rooms or communal areas. A tour of the premises confirmed service users had been allowed to bring their own personal possessions with them on admission to the home. Adelphi Rest Home DS0000005922.V280960.R01.S.doc Version 5.1 Page 12 On the day of the visit service users interest had been recorded on their file, there was a list on the board of social activities. The inspector spoke with several service users with regards the home social activities. All service users said that they felt the home provides the opportunity for social stimulation. Some service users said that they enjoyed this and others said that like to watch television or read. One service user said that she came into the home to relax and be looked after, therefore she did not want to participate in any thing that was offered. On the day of the visit Holy Communion was taking place with a small group of service users and bingo had been arranged for the afternoon. All service users said that they were very happy, comfortable and all felt that they were well cared for by the staff. Adelphi Rest Home DS0000005922.V280960.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 The home had a complaints procedure, which ensures that all complaints would be acknowledged and investigated. EVIDENCE: The home had not received any complaints at the time of the inspection. A complaints policy and procedure was in place and is made available to all service users in the service users guide. The home had a logbook to record complaints, however the registered provider should develop a format to record the complaint details. The logbook should be used for logging the complaint only. Both relatives and service users told the inspector they had no complaints but knew whom they could speak to if they had any concerns. The home monitors service users satisfaction through quality assessment questionnaires, these were seen by the inspector as positive. The registered person should ensure that these are dated. Adelphi Rest Home DS0000005922.V280960.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 and 26 The home was clean and tidy, which ensures service users live in a comfortable environment. However improvements are needed to ensure service users live in a safe environment. EVIDENCE: The home is kept warm clean and tidy. Carpets are cleaned regularly and the lounges are hovered after each mealtime. The carpet in the “Golden Lounge” is still in need of attention. The inspector was informed that the provider was currently considering some action with regards to this. Service users all said that they were comfortable in the home and that they had all they wanted. During a tour of the home the inspector noted that some parts of the home are in need of redecorating and the registered person should consider refurbishment of the bathroom on the first floor. The handy person informed the inspector that the provider did have plans to start re-decorating. The provider was not available on the day to discuss this with, therefore the Adelphi Rest Home DS0000005922.V280960.R01.S.doc Version 5.1 Page 15 registered person is advised to develop a refurbishment and redecoration programme to ensure that action is taken where needed. The handy person attends to all small maintenance in the home. Fire doors in the home continue to be wedged open, which is of concern and action, must be taken by the provider to address this. Adelphi Rest Home DS0000005922.V280960.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): 29 and 30 The policies and procedure for recruitment of staff provide safeguards for the protection of service users. Staff are provided with training to ensure they are competent to meet the needs of the service users living at the home. EVIDENCE: The home had a recruit policy and procedure in place, which ensured the Protection of Vulnerable Adults. The file of one newly appointed staff member was looked at. All the appropriate checked had been undertaken by the home prior to the staff member starting and an induction programme was in place to ensure the staff member was competent and confident to do the role of a carer. Staff on duty told the inspector that they felt well supported by the training provided and there was evidence that training was available for staff in the coming months. On the day of the visit some staff were ready for updates with regards to moving and handling and food hygiene courses. The registered person is advised to develop a training matrix, which will provide a tool for monitoring mandatory training. Adelphi Rest Home DS0000005922.V280960.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): 31,33,35 and 38 The home is well managed which ensures the service users interests are safeguarded. The practise of wedging open fire doors does not ensure the safety of service users. EVIDENCE: All staff receive training in health and safety practises. There were certificates on staff files to show that staff had received training with regards to moving and handling and food hygiene however some staff were awaiting up dates. There was evidence that one new staff had completed an induction programme and staff told the inspector that are provided with on going training to ensure they are competent in their job. The home appropriately records all accidents and there is a fire and environmental risk assessment in place. Since the last inspection the registered person had addressed the requirements in relation to Standard 38, however on the day of the visit the home fire doors remained to be wedged open. This was discussed with the person in charge. A Adelphi Rest Home DS0000005922.V280960.R01.S.doc Version 5.1 Page 18 requirement from this inspection will be for the registered person to contact the fire safety officer for advice with regards to this matter. Service users or their families manage the finances. The home provides a lockable storage area in all the bedrooms and fee payments are generally made via a relative. The home holds a small amount of money for some service users. All written records were seen maintained and up to date. On the day of the visit the person in charge was both competent and experienced however the inspector noted that she was required by the care staff to provide hands on care to assist service users out of bed. The person in charge also had to; respond to visitors, visiting professional and answer the telephone. The registered person should ensure that adequate supernumerary hours are provided to the manager to ensure she can fulfil her duties. Adelphi Rest Home DS0000005922.V280960.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 X X 3 X x X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 x 2 X X X X X X 2 STAFFING Standard No Score 27 X 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 X 3 X X 2 Adelphi Rest Home DS0000005922.V280960.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? yes 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. 2. Standard OP26 OP38 Regulation 16(2)(k) 23(4)(a) Requirement Timescale for action 30/09/05 The registered person must clean or replace the carpet in the golden lounge. The registered person must not 07/09/05 wedge fire doors open and seek advice with regards to this matter from the fire safety officer. 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. Refer to Standard OP9 OP12 OP14 OP16 Good Practice Recommendations The registered person should ensure that prescriptions are seen by the home before going to the Pharmacist. The provider should consider allocating a specific budget for activities within and outside the home. It is recommended that the home develops links with a local advocacy service and specific information made available to service users. The registered person should develop a format for recording complaints which takes into consideration the DS0000005922.V280960.R01.S.doc Version 5.1 Page 21 Adelphi Rest Home 5 6. 7. OP19 OP26 OP26 9. 10 11. 12. OP30 OP33OP16 OP31 OP38 Data Protection Act. The registered person is advised to develop a refurbishment and redecoration programme to ensure that action is taken where needed. It is recommended that the provider produce evidence that the premises comply with the Water Supply (Water Fittings) Regulations 1999. It is recommend that the infection control policy is revised to include information on the management of MRSA. It should also include instructions to staff on how to dispose of gloves and aprons. The registered person should develop a training matrix for monitoring mandatory training for staff. The registered person should ensure that quality assessment questionnaires are dated. The provider should give serious consideration to allocating designated supernumerary hours for the manager. The registered person should ensure that staff are kept up to date with moving and handling certificates. Adelphi Rest Home DS0000005922.V280960.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection North Lancashire Area Office 2nd Floor, Unit 1, Tustin Court Port Way Preston PR2 2YQ 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 Adelphi Rest Home DS0000005922.V280960.R01.S.doc Version 5.1 Page 23 - 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. 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