Inspection on 22/08/06 for Adey Gardens Care Home

This inspection was carried out on 22nd August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Adey Gardens Care Home 14/10/09

Adey Gardens Care Home 23/10/07

Adey Gardens Care Home 13/02/06

Adey Gardens Care Home 25/08/05

Adey Gardens Care Home 21/03/05

Adey Gardens Care Home 07/07/04

Adey Gardens Care Home 16/12/03

Similar services:

The Highlands

Turret Villa Retirement Home

Moor House

Blenheim House

1 Lanark Close

Mendip House

Beaconsfield Court Care Home

Ann Charlton Lodge

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

CARE HOMES FOR OLDER PEOPLE Adey Gardens Care Home South Street Newbottle Houghton Le Spring Tyne & Wear DH4 4EH Lead Inspector Irene Bowater Key Unannounced Inspection 09:00 22nd August 2006 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 Adey Gardens Care Home DS0000018185.V299114.R01.S.doc Version 5.2 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. Adey Gardens Care Home DS0000018185.V299114.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Adey Gardens Care Home Address South Street Newbottle Houghton Le Spring Tyne & Wear DH4 4EH 0191 512 0544 0191 512 0527 wendy_walker@btconnect.com 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) Rolamgold Limited (Muscat Walker & Hayim) Mrs Wendy Anne Walker Care Home 37 Category(ies) of Dementia - over 65 years of age (3), Old age, registration, with number not falling within any other category (34), of places Physical disability (25) Adey Gardens Care Home DS0000018185.V299114.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 13th February 2006 Brief Description of the Service: Adey Gardens is registered to accommodate up to 37 older people, 12 on the first floor who require personal care, including up to 3 people with dementia over the age of 65, and 25 people who require nursing care aged 50 and over are accommodated on the ground floor. This is a purpose built home situated in the village of Newbottle in Houghton-le- Spring. It is of traditional brick, two storey building set in pleasant, secure landscaped gardens on the edge of the village green. Nearby there are two restaurants and several public houses, a hairdressing salon, shops, a newsagent and post office. The bus stops outside the home, and transports to all local areas as well as to the cities of Sunderland and Durham. The home has a large reception area, leading to a spacious conservatory. Service users have access to a variety of lounges and dining areas with a separate designated smoking area. There is easy access to the home for those with disabilities, a passenger lift services both floors and there is a large car park provided. Fee rates range from £346.00 to £558.00.This includes the nursing band contribution, which is set nationally. Adey Gardens Care Home DS0000018185.V299114.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection took place over seven hours. The inspector spent time with the Registered Manager, staff, residents and visitors. The inspector looked around and talked to residents and staff, and saw the contact between them. Time was also spent checking the cleanliness, maintenance and decoration of the home. A number of documents were looked at including, training, maintenance, catering, medication, financial, recruitment, health and safety, and complaint records. What the service does well: The staff collect information together about the person before anyone moves into the home to make sure they can meet their needs. Staff often talk with other professionals to ensure residents health care needs are met. The staff team have good relationships with the residents. All of the residents said that “I am looked after”, “staff are kind and do a good job”, “it’s a nice place to live and I am happy with everything”. A relative said, “the staff are caring and look after my relative really well”. The meals are nutritious, nicely presented and choices are available. Residents agreed with this by saying, “the meals are nice”, “there’s plenty to eat”. Visitors are made welcome and there are good links with the local community. Residents spoken with said they knew who to complain to should if they were unhappy. Residents and relatives said “we know who to go to if we had a concern” and “any concern is always sorted out immediately by the staff”. The home is suitable for the people who live there and there is specialist equipment to meet their needs. A number of staff have worked together at the home for a long time. They said they get plenty of support from the senior staff and enjoy working at the home. Adey Gardens Care Home DS0000018185.V299114.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? The registered manager has worked hard to change things and make them better since the last inspection, within the time allowed. These include: • A sluice disinfector has been fitted in the sluice on the nursing unit. • • The recruitment and selection procedures are now being followed. Residents have been surveyed to find out what they think about the home. The registered manager has also finished a detailed training programme and all of the staff has received training in safe working practices, and Protection of Vulnerable Adults (POVA). 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. Adey Gardens Care Home DS0000018185.V299114.R01.S.doc Version 5.2 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 Adey Gardens Care Home DS0000018185.V299114.R01.S.doc Version 5.2 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, Standard 6 is not applicable The quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. The pre-admission assessments ensure the residents care needs will be met. EVIDENCE: Seven care plans looked at showed that the manager carries out comprehensive assessments before any resident is admitted to the home. The care managers and the nurse’s assessments were also available. The preadmission records are held in the managers’ office and form the basis of the computer-generated care planning process for the resident. Where possible the relatives or resident’s representative is involved in the assessment process. The relatives have been involved in the daily care of their relatives in regard to personal care giving and how their privacy is to be respected at visiting times. Information is also available about residents’ previous lifestyles and how this information will help residents to settle into the home. Adey Gardens Care Home DS0000018185.V299114.R01.S.doc Version 5.2 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): 7,8,9,10,11. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. The care planning system needs further improvement to provide staff, residents and their representatives with the information they need to meet resident’s needs. The health needs of all residents are being met. There is interagency working. The systems for the administration of medicines are now safe and consistent. Personal support is currently promoting residents right to privacy and dignity. EVIDENCE: Each resident has a care plan, which is based on the admission assessment. All of the care plans are computer generated. Four care plans from the nursing unit and three care plans from the residential unit showed that accredited assessments tools for the prevention of pressure sore and wound care, moving and assisting, catheter care, continence promotion, nutrition and mental health Adey Gardens Care Home DS0000018185.V299114.R01.S.doc Version 5.2 Page 10 status were completed. There was no evidence of risk assessments being completed for the safe use of bed rails. There was evidence that all of the care plans are regularly reviewed and updated according to changes in social, personal and health care needs. Residents who have reduced appetite and low body weights are weighed weekly and intervention sought from dieticians. Their recommendations are acted upon and the care plans updated as necessary. Up to date information regarding changes in wound care is documented on a regular basis and regular reviews take place with residents’, their relatives and care managers to make sure the home is still meeting their needs. The home manager is reviewing the care plans to enable the residents and their representative relevant and easy access. This will enable the plans to be readily available and easily understood. Access to the computer held records are password protected. The care plans identified resident’s preferences about how they wanted to be cared for and also took into account the wishes of their next of kin. The staff are respectful and carry out these wishes throughout the day. The residents have access to all NHS facilities to ensure their healthcare needs are met. There are regular visits from GP’s and other health professionals including dentists, opticians and chiropody services. There are appropriate pressure relieving devices available to support the staff and residents in daily activities. Several of the residents have air cell mattresses and cushions to prevent pressure damage. Advice is sought from tissue viability specialists, speech therapists and continence advisors. Visits from the multi disciplinary team are recorded in individual care plans. The district nursing services visits the residents who have social and personal care needs. The home has comprehensive medication policies and procedures for staff to use. Records are in place for all medicines received, administered and disposed of. An audit of Controlled Drugs and the Medicine Administration Records (M.A.R.) showed no discrepancies. There is a register of staff who are authorised to administer medication. However, four residents’ medications were dispensed into plastic medicine pots and left to be given out later by care staff. This poor practice was immediately brought to the attention of the registered manager and the practice stopped immediately. The medication administration and dispensing at lunchtime was satisfactory. Residents spoken to felt that they are treated with respect and their right to privacy is upheld. Residents spoke about their personal wishes and preferences, which are respected by staff and documented. Examples include Adey Gardens Care Home DS0000018185.V299114.R01.S.doc Version 5.2 Page 11 locking their bedroom doors, receiving their mail unopened, being addressed by their preferred name and being able to go wherever they wish in the home. There was a good rapport between staff, residents and relatives, which was friendly and professional. Care was delivered in private and staff were seen to knock on doors and wait for permission before entering. Several of the residents in the home have complex health care needs. The care plans are detailed about how their individual needs are to be met. Information about pain control is available and the Medication Administration Records and Controlled Drug records show that staff make sure that appropriate pain relief is given when the residents need it. The care plans record the wishes of the family and their involvement on a daily basis. The manager confirmed that support from the staff is always available for both the residents and their representatives. A qualified nurse is Palliative Care trained and the staff are receiving specialist training on a monthly basis. Adey Gardens Care Home DS0000018185.V299114.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to the service. Social activities do not provide stimulation and interest for residents living in the home. Support from relatives and representatives provide residents with opportunities to maintain their previous lifestyles. Residents are supported to make choices and take control over their lives. Dietary needs of residents are catered for with a balance of food available that meets residents’ needs. EVIDENCE: The home has been without a designated activities organiser for some time. The internal resident audit identified that this was the negative aspect of living in the home and this was confirmed throughout the inspection with residents saying, “it would be nice to have more going on” and “it’s a shame there are no activities planned in the home”. Currently there are no planned activities and on the day of inspection residents sat and watched television or waited for visitors to arrive. Adey Gardens Care Home DS0000018185.V299114.R01.S.doc Version 5.2 Page 13 Staff try to give residents the opportunity to take part in activities but this can be difficult given the complex and varied health needs of the residents. The residents who spent their days in their room were assisted to choose videos, music or had a member of staff spending some time with them. The staff on the upstairs unit knew in detail when residents would be going out with friends and family or when they would visit. One resident has a lot of visitors and the staff said the small lounge was available so that they can enjoy the visits in comfort. The staff said that residents sometimes play board games in the afternoons, or recently have spent time in the gardens enjoying the warm weather. Some good practice was observed with staff spending time with individuals however this is not recorded. And there are no systems in place for displaying information about community events and activities. Relatives and friends are made to feel welcome and know that they can visit at any time. There was a constant stream of visitors on the day of inspection and the staff took time to welcome them and discuss events with them. Residents are encouraged to take responsibility for their own financial affairs for as long as possible. The staff support anyone who needs assistance and involve families, advocates and care managers if there are any problems. Residents have been encouraged to bring small items of furniture and other belongings with them, making their rooms highly individualised and reflective of their lifestyles. On arrival at the home residents were enjoying breakfast, which was being served in the dining room or in residents own bedrooms. Breakfast choices include fruit juices, porridge, and choice of cereal and cooked breakfast, bread and toast with a choice of preserves and tea or coffee. Midmorning and afternoon drinks and biscuits were served and fresh fruit was available at any time. The home has dining rooms on each unit. The tables were appropriately set with tablecloths, napkins, crockery and condiments. The inspector observed the lunchtime meal being served on both units. The meals were served from hot trolleys as soon as they arrived from the kitchen. There was a choice of steak casserole or cheese omelettes served with mashed potatoes, broccoli and turnip. Residents had also asked for alternatives such and salad or sandwiches and these options were provided. There were a variety of puddings available including ice cream, yoghurt and fresh fruit including strawberries and other seasonal soft fruits. Hot and cold drinks were readily available throughout the meal. Both the care staff and kitchen staff were knowledgeable about individual residents needs for example those who needed soft or liquidised food, and diabetic diets. The staff assisted residents in a sensitive discreet manner and the mealtime was a pleasant unhurried time. Adey Gardens Care Home DS0000018185.V299114.R01.S.doc Version 5.2 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 the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. The complaints procedures are clear. Residents and relatives are confident that their views are listened to and acted upon. Arrangements for the Protection of Vulnerable Adults are satisfactory and protect residents from harm. EVIDENCE: There are detailed complaints procedures available in the home, which detail how to make a complaint. Records showed that all complaints are taken seriously and are investigated within 28-day time scales. Six residents said they would be able to use the procedure if necessary. Relatives said they had no cause for complaint but would go to the unit manager or registered manager if they had a concern. They said that any issue would be resolved as soon as possible and the registered manager was always available to talk to. There have been no complaints for over a year. There are policies and procedures in place for the Protection Of Vulnerable Adults and staff were able to discuss what to do should there be any allegation of abuse. The records show that forty of the staff have received abuse training since the last inspection. There have been no allegations of abuse. Adey Gardens Care Home DS0000018185.V299114.R01.S.doc Version 5.2 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 the following standard(s): 19,20,21,22,24,26. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to the service. The home is comfortable and clean and meets the needs of the people who live there. However, refurbishment/redecoration is not planned ahead to deal with the natural wear and tear. EVIDENCE: The location and layout of the home is suitable for the people who live there. A tour of the home found that all areas are being maintained, however there is no planned redecoration and refurbishment programme available to set out when furnishings and fittings are going to be replaced within timescales. There are lounges and dining rooms and each unit. All of these areas are furnished and decorated to a satisfactory standard although carpets are showing some signs of wear and tear. There is a large pleasant conservatory, which leads to landscaped secure gardens, which residents can freely access. The conservatory roof is still in need of repair as it leaks when raining. The Adey Gardens Care Home DS0000018185.V299114.R01.S.doc Version 5.2 Page 16 registered manager confirmed that quotes have been received and the roof needs total replacement. The work is to start next week September 4 2006 and work should be completed within three days. There are specialist bathrooms and toilets close to resident areas. Twenty-five bedrooms have en-suite toilets and some have a shower. The registered manager confirmed that the current residents do not use the shower facilities. The flooring in these areas is showing signs of wear and need replacing as part of an ongoing refurbishment programme. The registered manager said there were plans to change a domestic style bath with a walk in shower room. The sluices are separate from resident areas. The residents have access to all parts of the home and a passenger lift services the first floor. Specialist nursing profile beds, pressure prevention mattresses and cushions and chairs are available for individual residents use. The home has three hoists and residents who need to use these facilities have their own sling provided by the home. Bathrooms and toilets have assisted baths, toilets and grab rails. The home has a loop system in place for those who have a hearing impairment. A call system with an accessible alarm is provided in all resident areas. All of the rooms are being used for single occupancy. The bedrooms inspected are appropriately furnished and decorated. Many of the residents have brought items of furniture and other personal effects into the home making the rooms individual and reflecting their preferences and lifestyles. One bedroom upstairs next to the dining room requires the wallpaper repairing or replacing as it has been ripped from the wall. Some of the carpets require repairing or replacing, as they are showing signs of wear and tear. Each bedroom has a lockable facility and service users are offered keys unless their risk assessment suggests otherwise. Profiling beds are available for residents who require nursing care should they need them. On the day of inspection the home was clean, bright and fresh smelling. The laundry is situated on the first floor away from resident areas. The laundry was generally clean and organised. The washing machines stand on a wooden plinth, which has water stains, and this area will be difficult to clean on a daily basis. The ironing room is shared with the hairdressing room. The staff confirmed that on hairdressing day the ironing is done before or after the hairdresser is finished to promote a more enjoyable experience for the residents. A tour of the home found that the emergency call cords and light cords have become knotted and grimy. In order to minimise the risk of cross infection these need to be replaced to enable to staff to clean them on a daily basis. A sluice disinfector has been installed on the nursing unit. Adey Gardens Care Home DS0000018185.V299114.R01.S.doc Version 5.2 Page 17 Staff are aware of infection control procedures and use anti bacterial hand wash gel to minimise the risk of cross infection. Liquid soap and paper towels are available in bathrooms and toilets but are not provided in residents’ room to enable good hand washing. Adey Gardens Care Home DS0000018185.V299114.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome is good. This judgement has been made from evidence gathered both during and before the visit to the service. The current staffing levels and staff deployment ensures the residents assessed needs are met. The arrangements for training and recruitment ensure that residents are protected and staff are competent. EVIDENCE: The home has two units. The nursing unit is on the ground floor and is managed by qualified nursing staff and care staff. The upstairs unit does not provide nursing care and is managed by a unit manager and care staff. The registered manager is supernumerary, however works shifts on the nursing unit twice a week. There is a deputy manager in post. Since the last inspection a part time registered nurse has been recruited. Many of the staff have worked at the home for many years and have formed a stable staff team. An inspection of the staffing rotas showed that the staffing levels are currently meeting the residents’ needs. On the day of inspection the home was staffed as follows: Down stairs Unit 1 First level Registered Nurse throughout 24 hours Adey Gardens Care Home DS0000018185.V299114.R01.S.doc Version 5.2 Page 19 4 carers during the day 1 carer overnight Upstairs Unit 1 Unit manager or senior carer throughout 24 hours 1 carer throughout 24 hours. The registered manager was supernumerary. There were sufficient domestics, laundry assistants, cooks, kitchen staff and maintenance staff on duty. The home has over 90 of staff with NVQ level 2.The unit manager has NVQ level 4 and four staff have NVQ level 3. Four staff files with their training and development and supervision files were inspected. The records for recruitment were satisfactory. There was evidence of Criminal Record Bureau checks, Protection of Vulnerable Adult checks, two written references, proof of identity, professional identity numbers for registered nurses and completed signed induction programmes. Since the last inspection the registered manager and the staff have worked hard to complete a training programme in safe working practices. Individual records are available and certificates are being provided for all training undertaken. Evidence from the records and from discussion with staff confirms the following: Forty staff have received training in Abuse, Emergency First Aid, Health and Safety, Food Hygiene, Moving and Handling, Fire Prevention and Food Hygiene. Four staff have received training in the role of the care worker and four staff have been trained to enable them carry out supervision with the staff. A training and development programme is now available in the home and further specialist training should now be sourced especially in Parkinson’’ Disease, Multiple Sclerosis, Dementia care and dealing with challenging behaviours. The tissue viability nurse visits the home on a regular basis and is readily available for any training or support. Adey Gardens Care Home DS0000018185.V299114.R01.S.doc Version 5.2 Page 20 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): 31,33,35,36,38. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to the service. The home has an experienced manager who provides clear leadership. The systems for consultation and quality monitoring have improved with evidence that views of residents are sought and acted upon. Residents personal accounts are managed to ensure their best interests are protected. Staff do not receive the support and supervision they need to carry out their jobs. The lack of detailed risk assessments for the safe use of bedrails puts resident’s safety at risk. Adey Gardens Care Home DS0000018185.V299114.R01.S.doc Version 5.2 Page 21 EVIDENCE: The registered manager is a first level registered nurse with vast experience in care of the older person. She has to carry out regular training as a professional nurse in order to maintain Nursing and Midwifery Council requirements. She has completed the Registered Managers Award. The registered manager has recently sent out surveys to the residents to assess how the home is meeting their needs. The questionnaire covers, the staff, daily care, comfort and cleanliness, social activities, laundry, food, rights, privacy and independence and health and safety. The results are being collated and will be published in the Service User Guide. The only negative outcome has been lack of activities in the home and this is has been borne out through the inspection with comments from relatives saying “It would be nice to have more going on” and “It’s a shame there are no activities planned in the home”. There is evidence of staff meeting taking place with minutes being recorded. The registered manager confirmed that relative and resident meetings were not well attended and it is intended to have coffee mornings to provide a forum for them to air their views. Resident’s personal financial records were inspected. A record is maintained for each person’s transactions. Entries were clear with signatures available. The registered manager carries out regular audits. A random check of balances and cash were found to be correct. The registered manager confirmed that supervision has not been implemented. Senior staff have now been trained to carry out this important role and it expected that formal supervision would start shortly. Staff have now had training in safe working practices with records kept. Fire training is completed every three months for night staff and six months for day staff. Accidents are clearly recorded and the registered manager has started to complete monthly accident analysis to examine and track any trends using Sunderland’s’ Fall Prevention Strategy. Contract maintenance records were available and up to date. Water temperatures are recorded weekly to ensure temperatures of 44 C is not exceeded, or fall below. Thermostatic mixing valves are fitted to all baths and basins in residents’ areas. Adey Gardens Care Home DS0000018185.V299114.R01.S.doc Version 5.2 Page 22 During a tour of the home three residents were in bed and they had bed rails fitted. There was no evidence that rail protectors were being used on these beds although all other beds using bedrails had protectors available. The manager confirmed that risk assessments for the safe use of bedrails had not been completed and care plans not formulated. Adey Gardens Care Home DS0000018185.V299114.R01.S.doc Version 5.2 Page 23 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 2 2 3 X 2 X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 1 X 2 Adey Gardens Care Home DS0000018185.V299114.R01.S.doc Version 5.2 Page 24 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 Standard OP12 Regulation 12,16,23 Requirement The registered persons must consult residents about their social interests and make arrangements to engage in activities both inside and outside the home, which suits their needs, preferences and capacities. Up to date information about activities must be circulated to all residents in formats suited to their capacities. The registered persons must implement a programme of renewal and redecoration of the home with records kept. The registered persons must ensure that the conservatory is replaced to ensure there is no water ingress. Timescale of 31/10/05 and 31/05/06 not met. The registered persons must replace bathroom and toilet floorings as part of a refurbishment programme. The registered persons must ensure that the bath panel in the assisted bathroom is repaired. Timescale for action 01/10/06 2. OP19 23 01/10/06 3. OP20 23 30/09/06 4. OP21 23 01/03/07 5. OP21 23 30/09/06 Adey Gardens Care Home DS0000018185.V299114.R01.S.doc Version 5.2 Page 25 6. OP26 13 7. OP36 18 8. OP38 13,23 The registered persons must ensure all areas of the laundry are easily cleanable. The emergency call cords and light cords must be free from knots and easily cleanable. The registered persons must ensure that formal staff supervision is undertaken at least six times a year with records kept. The registered persons must ensure that risk assessments are implemented for the safe use of bedrails in accordance with the Medical Device Agency guidance. 01/10/06 01/03/07 30/09/06 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. Refer to Standard OP7 OP12 Good Practice Recommendations The registered persons should ensure that the care plans are accessible in residents’ bedrooms and in a style that they can understand. The registered persons should progress with the recruitment of an activities organiser to ensure residents are enabled to exercise choices in regard to leisure and social activities. The registered persons should implement a routine redecoration programme for bedrooms. The registered persons should consider providing liquid soap and paper towels in residents’ bedrooms to enable effective hand washing. 3. 4. OP24 OP26 Adey Gardens Care Home DS0000018185.V299114.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection South of Tyne Area Office Baltic House Port of Tyne Tyne Dock South Shields NE34 9PT 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 Adey Gardens Care Home DS0000018185.V299114.R01.S.doc Version 5.2 Page 27 - 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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