Inspection on 18/04/05 for Andrin House

This inspection was carried out on 18th April 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Andrin House 22/04/09

Andrin House 01/04/08

Andrin House 02/04/07

Andrin House 19/04/06

Andrin House 05/09/05

Andrin House 27/09/04

Andrin House 05/04/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Andrin House 43 Belper Road Derby DE1 3EP Lead Inspector Janet Morrow Unannounced 18th April 2005 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. Andrin House C02 C52 S2150 Andrin House V222213 180405 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Andrin House Address 43 Belper Road Belper Derby DE1 3EP 01332 346812 01332 204123 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) Rosecare Homes Limted Paticia Peart-Stubbs OP - Older People 37 Category(ies) of OP - Old Age registration, with number of places Andrin House C02 C52 S2150 Andrin House V222213 180405 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: The home has one place for a named individual under the age of 65 years. Date of last inspection 27th September 2004 Brief Description of the Service: Andrin House is a 37 bedded home with nursing for older people situated in a residential area close to the city centre of Derby. The property was originally a private dwelling, which has been converted into a care home. Service user bedrooms are located on the ground floor and first floor and are accessed by passenger shaft lift and staircase. Two bedrooms have en suite facilities. Personalised items are in the bedrooms. There are four communal rooms. Support services are in place with a choice of GPs, chiropodist, dentist and optician. Nursing services are provided as part of the care services of the home. Community psychiatric nurses, occupational therapists, physiotherapists and dieticians are accessed as required. Staff training takes place. Some entertainment is provided. Andrin House C02 C52 S2150 Andrin House V222213 180405 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection visit was unannounced and took place over 7.5 hours, with follow up telephone calls being made to relatives and visiting professionals. A second inspector, Bridgette Hill, assisted with the inspection from 10am until 3pm. Staff and care records were examined and a tour of the premises took place. Twelve of thirty- seven service users, two members of staff and one visiting professional were spoken to during the inspection. A further two relatives and a visiting professional were contacted by telephone following the inspection visit. What the service does well: What has improved since the last inspection? Some steps had been taken to improve the décor with damaged paintwork being repaired and new carpets being laid in the corridors. The main lounge had been re-arranged to make it more spacious. Improvements to some of the fire doors had been undertaken and a fire risk assessment completed. A sluicing disinfector had been provided but was not yet operational. Action had been taken to ensure water temperatures were safe. Andrin House C02 C52 S2150 Andrin House V222213 180405 Stage 4.doc Version 1.30 Page 6 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. Andrin House C02 C52 S2150 Andrin House V222213 180405 Stage 4.doc Version 1.30 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 Andrin House C02 C52 S2150 Andrin House V222213 180405 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, and 3 The home provided sufficient information in its statement of purpose to enable service users to make an informed choice. Terms and conditions of residence (contract) ensured that contractual obligations were met, with the exception of nursing care costs. Assessment information was not available on all files and there was therefore the potential for service users’ needs not to be addressed. EVIDENCE: The statement of purpose contained comprehensive information and met the requirements of Schedule 1 of the Care Homes Regulations 2001. Terms and conditions of residence (contract) were in place but needed to specify the cost of the nursing element of care. Four service users’ files were examined and one did not have any assessment undertaken by the home and the standardised care plan in place was not personalised. There were specific needs identified by the information provided from social services but these had not been addressed through the home’s assessment. Andrin House C02 C52 S2150 Andrin House V222213 180405 Stage 4.doc Version 1.30 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9, 10 Limited progress had been made on improving arrangements to ensure that the health care needs of service users were met consistently. These shortfalls have the potential to place service users at risk. EVIDENCE: The four care files examined showed that recording was inconsistent. On all four files there was no care plan to meet social and psychological needs and not all had completed risk assessments for falls, tissue viability or nutrition. The plans had not been reviewed regularly; for example one care plan had not been reviewed since January 2004 and there was intermittent completion of the daily nursing log with gaps of up to two months between recordings. Poor medication administration procedures were observed with several service users medicines being put out at the same time in pots prior to being given. There was also a loose tablet found on the floor in the office. One service user was observed to have eye drops dispensed for another and medication administration record (MAR) charts showed that one service user had been given a medicine they were allergic to. There was also no maximum dose for an ‘as required ‘medicine for one service user. These practices have the potential to put service users at risk. Andrin House C02 C52 S2150 Andrin House V222213 180405 Stage 4.doc Version 1.30 Page 10 Service users spoken to said that staff were kind and one stated that she ‘never heard a cross word’. Staff were observed to have warm relationships with service users and privacy was observed. One service user interviewed had, however, been left in soiled clothing after vomiting. Andrin House C02 C52 S2150 Andrin House V222213 180405 Stage 4.doc Version 1.30 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 standard(s) 13 and 15 Contact with visitors was on an open basis and meals were varied and nutritious. EVIDENCE: Visitors interviewed, both during and after the inspection, stated that they were made to feel welcome and that manager and staff were approachable. The serving of the lunchtime meal was observed and those service users interviewed stated that they enjoyed their meals, which appeared plentiful and nutritious. Those service users requiring assistance to eat were offered help in a sensitive manner. However, those service users with sight problems were not aware of the contents of their meals. Andrin House C02 C52 S2150 Andrin House V222213 180405 Stage 4.doc Version 1.30 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 Complaints were handled objectively and service users and their relatives were confident that their concerns would be listened to and dealt with accordingly. Service users were protected from abuse. EVIDENCE: The home had a clear complaints procedure and those service users interviewed stated that they were confident of a courteous response to any concerns. An up to date adult protection policy was in place and the manager was aware of Derby and Derbyshire Social Services Local Authority procedures. Certificates were available confirming that staff training in adult protection and dealing with challenging behaviour had taken place. However, newer members of staff had not been trained in adult protection. Andrin House C02 C52 S2150 Andrin House V222213 180405 Stage 4.doc Version 1.30 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 22 and 24 Some improvements to the décor, fire doors and water temperatures had been made which had improved the general safety for service users. However, other improvements are needed to ensure the ongoing comfort of service users. EVIDENCE: Since the last inspection, the home had made efforts to repair damaged wall paper and paintwork and new carpets had been laid in corridors. However, some armchairs in the main lounge and smoking area were shabby and there were areas on the carpet in the lounge that were stained. One wheelchair was observed to be dirty and another had a broken foot strap and footplate. There was sufficient equipment in place to meet the needs of service users with disabilities. Bedrooms were personalised although some did not have lockable storage space. A programme of fitting locks to bedroom doors was underway. Andrin House C02 C52 S2150 Andrin House V222213 180405 Stage 4.doc Version 1.30 Page 14 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, 29 and 30 The procedures for the recruitment of staff were robust and provided safeguards for people living in the home, although new legislation had brought in additional requirements to the information held on staff files. Staff training enabled staff to perform their roles competently. EVIDENCE: Staff rotas for the 4th April 2005 –1st May 2005were examined and showed that there were sufficient staff on duty to meet service users’ needs. Four staff files were examined and all had relevant identity information in place. All had Criminal Record Bureau checks in place with the exception of one, which was about to be processed. However, there was no evidence to suggest that gaps in employment were investigated, as brought in by legislation in July 2004. Staff interviewed confirmed that they had access to training that covered health and safety issues, as well as training that was relevant to the care provided at the home such as tissue viability and dealing with challenging behaviour. However, a trained member of staff interviewed had not done first aid training or protection of vulnerable adults training. Discussion with service users with sight loss indicated that additional training for staff on visual awareness would be useful. Andrin House C02 C52 S2150 Andrin House V222213 180405 Stage 4.doc Version 1.30 Page 15 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, 37, 38 There was leadership and guidance to staff to ensure that care needs and health and safety needs were met. There had been no progress on developing plans for ensuring the quality of the service and it was unclear whether the service was run in the best interests of service users. EVIDENCE: The registered manager was competent to run the home and had completed the Registered Manager’s award. Service users interviewed were clear that the manager was in charge, with one describing her as ‘marvellous’ and that she ‘understands’. There had been no progress on quality assurance plans since the last inspection and there was no formal mechanism for service users to register their views of the home. Records for the running of the home were in place. Some of those examined such as staff files needed additional information to fully meet the requirements of the Care Homes Regulations 2001. Andrin House C02 C52 S2150 Andrin House V222213 180405 Stage 4.doc Version 1.30 Page 16 Health and safety needs were addressed through staff training. Fire records and maintenance of equipment records such as gas, lift and electrical wiring were all up to date. Andrin House C02 C52 S2150 Andrin House V222213 180405 Stage 4.doc Version 1.30 Page 17 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 3 2 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 2 3 2 x 2 x x STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 x 2 x x 3 2 3 Andrin House C02 C52 S2150 Andrin House V222213 180405 Stage 4.doc Version 1.30 Page 18 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard op29 Regulation 19 (1) Requirement Recruitment procedures must be updated to ensure all records required are in staff files as per Schedules 2 & 4 of the Regulations. (Previous timescale of 1.8.04 not met) Locks must be provided to bedroom doors and keys provided for those service users who wish to have them. (Previous timescale of 1.8.04 not met) Interventions to maintain oral health and social interests must be recorded. Previous timescale of 1.3.04 not met Interventions to maintain psychological health and mobility must be fully recorded. Previous timescale of 1.3.04 not met Assessment documentation must be fully completed. Previous timescale of 1.2.05 not met. A care plan must be available for needs identified in assessment documentation. Previous timescale of 1.12.04 Timescale for action 1st June 05improvements made 1st June 05improvements made 1st June 05 2. op24 12 (4) (a) 3. op7 15 (1) 4. op8 12 (1) 1st June 05 5. op3 14 (1) (a) 1st June 05 6. op7 15 (1) 1st June 05 Andrin House C02 C52 S2150 Andrin House V222213 180405 Stage 4.doc Version 1.30 Page 19 not met 7. op24 16 (2) (c) All bedrooms must be provided with two comfortable seats, two double electrical sockets and a table to sit at. Reasons not to provide these items must be recorded in service users’ files. Previous timescale of 1.1.05 not met An annual development plan for quality assurance must be available. Previous timescale of 1.1.05 not met Nursing care costs must be detailed in the terms and conditions of residence. Service users plans must be kept under review. Medicines must be administered according to Royal Pharnaceutical Society procedures Medicines must be administered only to the service user named on the container. As required medicines must detail a maximum dosage. Soiled clothing must be changed to maintain dignity and comfort. Armchairs in the lounge must be replaced or refurbished. 1st August 05 8. op33 24 (1) 1st August 05 9. 10. 11. op2 op7 op9 5A (2) 15 (2) (b) 13 (2) 1st August 05 1st August 05 1st August 05 1st August 05 12. 13. 14. 15. 16. 17. op9 op9 op10 op20 op22 op37 13 (2) 13 (2) 12 (4) (a) 23 (2) (d) & 23 (2) (c) 23 (2) (c) 17, Schedules 1-4 1st August 05 1st August 05 1st November 05 All wheelchairs must be kept 1st August clean and have all components in 05 working order. All information required by 1st August Schedules 1 - 4 of the Care 05 Homes Regulations 2001 must be in place in staff and service user files. Andrin House C02 C52 S2150 Andrin House V222213 180405 Stage 4.doc Version 1.30 Page 20 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 op34 op12 op22 op18 op27 op33 op18 op15 & 30 Good Practice Recommendations A business plan should be in place. Information should be accurate and provided in a variety of formats to suit individual needs such as large print, on tape etc. The premises should be assessed by an Occupational Therapist. The home’s own adult protection policy should make reference to Derby and Derbyshire Local Authority procedures. Care staff hours at peak times of day should be reviewed. The review of policies and procedures should indicate the outcome and any action required. There should be a system in place to ensure that all new members of staff receive training in adult protection. Staff should receive training in visual awareness. Andrin House C02 C52 S2150 Andrin House V222213 180405 Stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection South Point, Cardinal Square Nottingham Road Derby DE1 3QT 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 Andrin House C02 C52 S2150 Andrin House V222213 180405 Stage 4.doc Version 1.30 Page 22 - 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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