Inspection on 06/09/05 for Adelphi Rest Home

This inspection was carried out on 6th 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Adelphi Rest Home 20/07/06

Adelphi Rest Home 02/02/06

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 Announced 06 September 2005 09:30 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. Adelphi Rest Home F57 F08 S5922 Adelphi V238119 060905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Adelphi Rest Home Address 33/35 Queens Road Chorley Lancashire PR7 1LA 01257 271361 01257 271361 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) Mr Barry Brown Mrs Jacqueline Taylor Care Home 27 Category(ies) of OP - Old age (27) registration, with number of places Adelphi Rest Home F57 F08 S5922 Adelphi V238119 060905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25 October 2004 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 F57 F08 S5922 Adelphi V238119 060905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection that took place over one day in September 2005. The management team had addressed a number of matters raised at the last inspection and the number of requirements had been significantly reduced. However some areas still need to be improved and so some requirements and recommendations have been made. The inspection involved discussion with the people who lived and worked at the home, examination of records, a tour of the home and information received from questionnaires sent to relatives and service users. A separate pharmacy inspection was carried out by the Pharmacist Inspector. The outcome of this inspection, together with any requirements and recommendations has been sent to the provider in a separate report. What the service does well: What has improved since the last inspection? There has been a number of improvements since the last inspection. Training is on going for staff and a significant number of staff had completed their NVQ qualification, the remaining staff team were working towards completing the course. Staff are kept up to date with mandatory training and supervision sessions were seen documented on staff files. A checklist had been developed to ensure that all staff files contain all the appropriate documentation and checks required by law. However two new staff had started prior documentation being received, this was discussed with the registered manager on the day. Adelphi Rest Home F57 F08 S5922 Adelphi V238119 060905 Stage 4.doc Version 1.40 Page 6 The registered manager had worked hard to develop assessments and care plans and assessments had been undertaken for all new service users, however further work is needed in this area. What they could do better: 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 F57 F08 S5922 Adelphi V238119 060905 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 Adelphi Rest Home F57 F08 S5922 Adelphi V238119 060905 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) 3 and 4 The home had a pre-admission process in place, however not all information had been documented to ensure individual needs were identified. EVIDENCE: The home had undertaken a pre-admission assessments for all new service users and both a service user and their family confirmed that they had been given the opportunity to be involved in this process. The files of two new service users were viewed in detail as part of the inspection process. Each service users file contained a number of records / charts and documentation for assessing individual needs. However on the day of the visit not all assessed needs had been identified via this assessment process and the lengthy assessment process did not provide a clear picture of the service users needs. One service users assessment did not include information relating to her physical disability. The inspector discussed with the manager the opportunity to refine and reduce the amount of paper work used by the home for undertaking assessments, which would clearly identify service users needs and ensure all needs could be met by the home. Adelphi Rest Home F57 F08 S5922 Adelphi V238119 060905 Stage 4.doc Version 1.40 Page 9 Discussion with the staff team, service users and their family members confirmed that service users needs were being met even though there was a lack of information on the assessment and care plan. The manager confirmed that care staff rely on daily instructions and use their own knowledge of the service users. If this informal system breaks down the service users would be at risk of not having their needs met. Service users spoken too said that they were very happy with the care they received and felt all their needs were being met. The home had a training programme in place and staff members told the inspector that they felt well supported by the management and training provided. Adelphi Rest Home F57 F08 S5922 Adelphi V238119 060905 Stage 4.doc Version 1.40 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 standard(s) 7,10 Each service users had an individual care plan, more detail is needed to ensure that service users needs are fully identified and met. Service users are cared for in such away that ensures their dignity and privacy is upheld. EVIDENCE: Individual care plans were in place but do not provide enough detail in the way of written instructions for staff on how the identified assessed needs are to be met. One care plan did not provide information for staff on how to meet the needs of a service user with incontinence problems. Another service users care plan stated that the district nurse visited each day but the manager said that she only attends once a week. However discussion with staff, service users and relatives suggested that, the needs of the service users were being addressed through the homes informal communication systems. Senior care staff communicate verbally to other carers and significant events are recorded on the daily record sheets. Service users would be at risk of not having their needs met if these informal systems break down or if senior experienced staff leave. The manager should ensure that the care plans are updated and used by the care staff as a working document. Adelphi Rest Home F57 F08 S5922 Adelphi V238119 060905 Stage 4.doc Version 1.40 Page 11 The manager informed the inspector that the night staff have been instructed to complete the daily diary sheet for any service users that had not had an entry by the day staff. The inspector discussed with the manager the importance of accurate and up to date recording of information. Therefore, day staff should complete a daily record which should include the range of care provided and the night staff should complete the night record. Service users told the inspector that the staff are very kind and treat them with respect and the inspector saw examples of staff caring and speaking to service users in a sensitive and caring manner. Adelphi Rest Home F57 F08 S5922 Adelphi V238119 060905 Stage 4.doc Version 1.40 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 standard(s) 12 and 15 The dietary needs of the service users are well catered for with a balanced and varied selection of food available that ensures service users individual tastes and choices are catered for. Social activities are available but do not meet the expectation of the people living at the Adelphi. EVIDENCE: The food is cooked in the homes kitchen and fresh produce was seen being used. All service users spoken too said that the food was very good and that they were always offered a choice if they didn’t like what was on the days menu. The dining tables were pleasantly laid out and service users had both a hot and cold drink on the table. Special diets were provided for those service users requiring one and attention was given to the presentation of soft diets. Service users were unhurried, and enough time was given to service users requiring assistance. Since the last inspection the cook had completed an NVQ qualification. Service users and their family told the inspector that they felt the home provided flexibility and choice with regards to the daily living. However a number of comments received from both service users and relatives felt that there was not enough activities or stimulation offered in the home. One service said that she often gets bored and another service users said that she had been out for a trip in the minibus a couple of weeks go but there had been Adelphi Rest Home F57 F08 S5922 Adelphi V238119 060905 Stage 4.doc Version 1.40 Page 13 nothing offered since. The manager told the inspector that the activity coordinator was currently off on long term sick and although a member of staff had been selected to undertake activities a programme of activities had not been developed. The manager told the inspector that the service users had shown very little interest in the activities offered. The inspector noted that the needs of the service users living in the home varied, therefore the registered person should consult with each service users and take into consideration the service users abilities and ensure that service users social and recreational interests are recorded and how they are to be met. Adelphi Rest Home F57 F08 S5922 Adelphi V238119 060905 Stage 4.doc Version 1.40 Page 14 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) 18 Arrangements for the protection of service users ensures the safety of service users. EVIDENCE: The home had a procedure in place for dealing with allegations of abuse and the staff were able to confirmed the correct procedure they would follow to protect service users. A requirement from the last inspection that the registered person reviews the home policy for managing service users with challenging behaviour had been addressed through the providers action plan. Adelphi Rest Home F57 F08 S5922 Adelphi V238119 060905 Stage 4.doc Version 1.40 Page 15 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) 26 The premises were clean and tidy which ensured service users live in a comfortable environment. EVIDENCE: The home was kept clean and tidy. Carpets are cleaned regularly and the dining room is hovered after each meal time. Service users said they were very comfortable in the home and that they had all they wanted. One relative said that her mums bedroom was always kept very clean and tidy. On the day of the visit one carpet in the “golden” lounge had a stain and an odour was present. The manager told the inspector that the carpet had been cleaned but needed doing again. This will need to be addressed. The laundry is situated in the basement and the facilities were appropriate for the home purpose. Instructions were available in the laundry for staff to follow and aprons and gloves were situated in the laundry, toilets and bathrooms. Adelphi Rest Home F57 F08 S5922 Adelphi V238119 060905 Stage 4.doc Version 1.40 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 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 29 The procedures for the recruitment of staff did not safeguard service users. Staffing numbers are sufficient to meet the services users needs and the staff are provided with training to ensure they are competent to do the job. EVIDENCE: On the day of the visit a number of staff files were examined. Since the last inspection the home had developed a check list to ensure that staff files contained all the appropriate documentation and checks required by law. However the inspector noted that two new staff members had started employment prior to CRB disclosures being obtained, the inspector discussed the seriousness of this matter with the registered manager. The new staff files contained information in relation to induction training and one new carer was able to confirm this. Training was available for all existing staff and certificates were seen on the staff files. All staff were provided with mandatory training and a training date had been booked to update staff with moving and handling techniques. Staff said that they felt well supported by the training offered. Since the last inspection a number of staff had completed the NVQ Level 2 qualification and number of staff were working towards the qualification. Staffing levels in the home were sufficient for the number of service users living in the home. Staff spoken too said that they felt they had enough staff on duty to meet the needs of the current service users. There was a rota available in the home showing staff on duty. Adelphi Rest Home F57 F08 S5922 Adelphi V238119 060905 Stage 4.doc Version 1.40 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 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) 38 The current management processes do not make sure that systems and procedures are in place to ensure the safety of service users. EVIDENCE: On the day of the visit the registered provider was on holiday and had left a number of certificates for inspection. However there were no certificates or documentation available for the following; - Servicing of gas appliances including the gas boiler. - No certificate or evidence that the Water meets with the Water Supply (Water Fittings) Regulations 1999 - No evidence that the water is stored and distributed at appropriate temperatures to prevent legionella. - The home’s last fire officer report. - The home’s fire risk assessment. - The home’s environmental risk assessment. Adelphi Rest Home F57 F08 S5922 Adelphi V238119 060905 Stage 4.doc Version 1.40 Page 18 On the day of the visit the fire doors had been wedged opened, the manager told the inspector that staff had placed the wedges in the doors while hoovering. The manager was informed that the fire doors must not be wedged open at any time. Fire guards in both lounges were not fixed to the wall which does not ensure safety of a service user if they were to fall against them. One bed in a first floor bedroom had been placed next to a large single pained window, the registered person must ensure that a risk assessment is undertaken and action taken to minimise any risk. Staff were able to confirm that they had received training in relation to health and safety and service users spoken too said that they felt safe living at Adelphi. Adelphi Rest Home F57 F08 S5922 Adelphi V238119 060905 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 2 x 3 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 2 13 x 14 x 15 3 COMPLAINTS AND PROTECTION x x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 3 x x x x x x x 2 Adelphi Rest Home F57 F08 S5922 Adelphi V238119 060905 Stage 4.doc Version 1.40 Page 20 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 3 Regulation 14(1) Requirement The registered person must review the homes assessment format to ensure that all needs are identified and recorded.(Timescale of 31/1/05 not met.) The registered person must ensure that the care plan provides written instruction on how the assessed need including health care needs are to be met. (Timescale of 31/1/05 not met.) The registered person must ensure that service users social, and recreational interests are recorded and met.(Timescale of 31/1/05 not met.) The registered person must clean or replace the carpet in the golden lounge. The registered person must ensure that all new staff are confirmed in post following completion of a POVA first check and a satisfactory CRB disclosure. The registered person must undertake a risk assessment for bed placed against the window in the first floor bedroom and take Timescale for action 30/11/05 2. 7,8 15(1) 30/11/05 3. 12 16(2)(m)( n) 30/11/05 4. 5. 26 29 16(2)(k) 19 Schedule 2 30/9/05 7/9/05 6. 38 13(4) C 30/9/05 Adelphi Rest Home F57 F08 S5922 Adelphi V238119 060905 Stage 4.doc Version 1.40 Page 21 7. 38 23(4)(a) 8. 38 23(4)(a) 9. 10. 38 38 23(4)(a) 23(2) (c approprate action to minimse any risks identified. The registered person must ensure that the guards on the lounge fires ensure the safety of service users at all times. The registered person must ensure that there is a current up to date fire risk assessment available for the person in charge. The registered person must not wedge fire doors open. The registered person must ensure that the gas appliances including the boiler in the home are safe for use. 30/9/05 30/9/05 7/9/05 30/9/05 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. 6. 7. 8. Refer to Standard 3 3 7 12 12 14,17 16 26 Good Practice Recommendations The registered person should consider reducing and refining the number of documents used for assessments of service users needs. The registered person should ensure that the assessment covers the list identified in Standard 3.3 of the National Minimum Standard. The registered person should ensure that a daily record is made for each service users. The provider should consider allocating a specific budget for activities within and outside the home. The provider should ensure that up to date information is displayed on the notice board. Activities that do not take place should not be advertised. 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 ensure that the complaints book is paginated and only one entry made on each page. It is recommended that the provider produce evidence that the premises comply with the Water Supply (Water F57 F08 S5922 Adelphi V238119 060905 Stage 4.doc Version 1.40 Page 22 Adelphi Rest Home 9. 26 10. 11. 12. 13. 29 31 32 33 14. 15. 35 38 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 consider revising the homes application form to comply with Equal Opportunites emplyment legislation. The provider should give serious consideration to allocating designated supernumerary hours for the manager. The provider should ensure that regular staff and service users meetings are held and that records kept of such meetings. It is recommended that the home undertakes and publishes the results of service user surveys, and also actively seeks the views of family, friends and stakeholders in the community in respect of the home The provider should ensure that when money is handed over to relatives for banking/safekeeping that they sign the financial record. The provider should provide evidence that water is stored and distributed at appropriate temperatures to prevent risks from Legionella 16. Adelphi Rest Home F57 F08 S5922 Adelphi V238119 060905 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection Levens House Ackhurst Business Park Foxhole Road Chorley, Lancashire, PR7 1NW 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 F57 F08 S5922 Adelphi V238119 060905 Stage 4.doc Version 1.40 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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