Inspection on 19/04/06 for Andrin House

This inspection was carried out on 19th April 2006.

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 05/09/05

Andrin House 18/04/05

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 Inspection 09:15 19th April 2006 and 20th April 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 Andrin House DS0000002150.V290563.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Andrin House DS0000002150.V290563.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Andrin House Address 43 Belper Road Derby DE1 3EP 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) 01332 346812 01332 204128 Rosecare Homes Limited Patricia Peart-Stubbs Care Home 37 Category(ies) of Old age, not falling within any other category registration, with number (37) of places Andrin House DS0000002150.V290563.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: One named individual aged under 65 years (DG). Date of last inspection 5th September 2005 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. Residents’ bedrooms are located on the ground floor and first floor and are accessed by passenger shaft lift and staircase. Three 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 DS0000002150.V290563.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection visit was unannounced and took place over two days for a total of 10.5 hours. Staff and care records were examined. A partial tour of the building was undertaken. The home had five vacancies. Nine of the thirty-two residents, and two relatives were spoken to during the inspection. One relative was contacted by telephone following the inspection. The staff meeting was observed. Since the last inspection in September 2005, monthly monitoring visits had taken place until February 2006 in response to adult protection issues and complaints regarding the care raised during that inspection. The home had provided an action plan on how the issues raised were to be addressed. No further complaints had been received at the office of the Commission for Social Care Inspection. What the service does well: What has improved since the last inspection? Following the care issues raised at the last inspection in September 2006, the home had improved its care plans to ensure identified needs were addressed and better monitoring of health took place. Staff training in specified areas such as dying and bereavement had taken place in response to issues raised in the complaints. New armchairs had been supplied in the lounge and scratch marks on doors and corridors had been repaired and the garden area had been tidied. Two double electrical sockets had been provided in all bedrooms for those residents who wanted them. A wider range of entertainment was being provided with an activity taking place each afternoon. Andrin House DS0000002150.V290563.R01.S.doc Version 5.1 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 DS0000002150.V290563.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Andrin House DS0000002150.V290563.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 3 The home’s assessment information had improved, which established that the home was able to meet individual residents’ needs. Terms and conditions of residence (contract) did not fully meet legal requirements, which had the potential for confusion about contractual obligations. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Four residents’ care files were examined. All had an assessment in place including one completed by the home and also from the assessment and care management process, where applicable. Falls were addressed briefly in the moving and handling assessment but there was no specific assessment tool in use to identify risk of falls. Terms and conditions of residence (contract) were discussed with the manager who stated that these were unchanged since the last inspection. This meant that they still did not specify the breakdown of costs into accommodation, personal care and nursing care as required by the Care Homes Regulations 2001. Andrin House DS0000002150.V290563.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Improvement in care planning and health monitoring had addressed some of the issues raised previously, which ensured that residents’ needs were addressed in a more consistent manner. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Four residents’ care files were examined. Care plans were in place in all those examined. The consistency in care planning had improved and all care plans examined had details on how to provide care where a risk assessment had indicated intervention was required. For example, on all files examined there was a risk assessment for tissue viability and appropriate care plans, although one could have contained more specific detail. Care plans were being reviewed on a monthly basis. Recording of weight, blood pressure and temperature was occurring on a monthly basis. However, there was one record of significantly raised blood pressure for one resident that had not been followed up or rechecked. Andrin House DS0000002150.V290563.R01.S.doc Version 5.1 Page 10 The main omission was regarding interventions to prevent falls. There was no specific risk assessment and as a consequence no specific care plan, although general comments re use of walking aids and supervision were supplied in care plans regarding mobility. This was the case in all four files, including one where falls for a specific resident had been recorded in the accident report book. Only one of the four files examined had evidence of consultation with residents, such as a signature, about their care. There was positive feedback from both relatives and residents about the care and the carers. One resident commended the staff for their honesty in returning lost cash, another described them as ‘great’ and a relative said they were ‘pleased’ with the care provided. All interviewed felt they were treated with dignity and respect. The medication administration record (MAR) charts for four residents were examined and on the whole were in order. However, one chart was hand written and had not been signed and dated by two people; the dosage for one medicine on this chart differed to that on the container label. The controlled drugs record was examined and the record corresponded with the drugs held. Medicines were stored securely. Andrin House DS0000002150.V290563.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 and 15 Visiting, meals and activities were well managed, which enhanced residents’ daily lives. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: All relatives interviewed stated that they were made to feel welcome at the home and could visit at any time, with one relative describing it as a ‘lovely place’. The serving of the midday meal was observed and those residents spoken with said they enjoyed the food. Those residents’ requiring help with feeding were assisted in a sensitive manner. Menus were examined and showed that nutritious meals were on offer and that a choice was available. The stocks of food in the kitchen were seen and were plentiful. Frozen vegetables were used and there was no fresh fruit available. The kitchen staff stated that this was because fresh vegetables and fruit had previously gone to waste. One resident wanted particular food and staff tried to accommodate this, although not always to his satisfaction. There was information available in the kitchen about specialist needs for specific residents. Andrin House DS0000002150.V290563.R01.S.doc Version 5.1 Page 12 The manager had introduced a programme of activities to ensure that some activity took place each afternoon. This was appreciated by those residents who wished to take part, although some wanted a wider range to accommodate personal interests. A relative also commented that a wider range of activities would be beneficial. Andrin House DS0000002150.V290563.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The objective handling of complaints, clear adult protection procedures and staff awareness ensured that residents were protected from abuse. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The complaints record was examined and showed that the manager investigated complaints and recorded their outcomes. Those relatives interviewed said that they would contact the manager if they had any concerns and were confident of a courteous response. Adult protection procedures were in place and the involvement in the procedures following the last inspection in September 2005 had ensured that the manager was fully aware of what to do in the event of an allegation. Staff training certificates showed that staff had received training in adult protection in November 2005. Andrin House DS0000002150.V290563.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 22, 23 and 26 The environment was generally safe but further refurbishment would enhance the ongoing comfort of residents. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The home was generally well maintained although continued attention in some areas was needed, such as the dining tables and the smoking room, which appeared shabby. New armchairs had been provided in the main lounge and improvements to bedrooms, such as the installation of two double electrical sockets, had been made. The garden area at the side of the home had been tidied. There was sufficient equipment to meet the needs of those with physical disabilities, including hand rails, bath hoists, raised toilet seats, wheelchairs and hoists. Andrin House DS0000002150.V290563.R01.S.doc Version 5.1 Page 15 There had been no changes to room sizes since the last inspection in September 2006. The laundry was tidy and washing machines had a sluice wash facility. The home was clean, tidy and odour free. However, the home did not have a sluicing disinfector. Andrin House DS0000002150.V290563.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 There were sufficient qualified and experienced staff deployed to meet residents’ needs. Omissions in recruitment procedures had the potential to compromise residents’ safety. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The staff rota for the week of the inspection (beginning 17th April 2006) was examined and showed that there were sufficient staff on duty to meet residents’ needs. There were two trained nurses on the morning shift and two in the afternoons until six p.m. There were five care staff on each shift. There were two kitchen staff and two domestic staff on duty each day plus one laundry staff member and a handyperson. Discussion in the staff meeting did not identify any staffing issues, apart from shortages due to unexpected sick leave and when induction of new staff was taking place. The home was meeting the target of having 50 of staff qualified to National Vocational Qualifications (NVQ) Level 2 as ten of twenty care staff had achieved the award with a further three currently undertaking the course. Additional staff training took place and courses on dying and bereavement, adult protection and wound management had taken place since the last inspection in September 2005. Health and safety courses had also taken place over the last twelve months. The discussion in the staff meeting identified that training in dealing with difficult and challenging behaviour would be beneficial. Andrin House DS0000002150.V290563.R01.S.doc Version 5.1 Page 17 Three staff files were examined and showed that there were omissions in the information required by Schedule 2 of the Care Homes Regulations 2001. Two files had no Criminal Record Bureau check and another had only one written reference. There was also no evidence of qualification in one file for a trained member of staff. An immediate requirement notice was issued to ensure that Criminal Record Bureau checks, written references and proof of qualification were in place on all files. Andrin House DS0000002150.V290563.R01.S.doc Version 5.1 Page 18 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, 37 and 38 Quality assurance processes were unclear and there were gaps in record keeping, which did not ensure that the home was run in residents’ best interests. Health and safety was addressed for all involved in the home. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The registered manager had completed the Registered Manager’s award and had over four years experience in running the home. Residents and relatives interviewed were clear that the manager was in charge, with one relative describing her as ‘good’ and another as ‘approachable’. Andrin House DS0000002150.V290563.R01.S.doc Version 5.1 Page 19 There was no information available on quality assurance such as an annual plan or responses to questionnaires. There was also no feedback from any professional visitors. This was raised as an issue at the previous inspection in September 2005 and an immediate requirement notice was issued to ensure that action on quality assurance was taken. Relatives interviewed confirmed that there had been a meeting for them where any issues of concern could be raised. Records for the running of the home were in place. Some of those examined such as staff files and care files needed additional information to fully meet the requirements of the Care Homes Regulations 2001. Health and safety was generally addressed with staff having undertaken training courses in mandatory areas such as moving and handling, first aid, fire safety and food hygiene. However, there was no record of infection control training having been undertaken. Examination of hoists and fire extinguishers showed that these had been checked in January 2006. The accident report book was examined and corresponded with entries in residents’ files. The record of fridge and freezer temperatures showed that these were recorded on a daily basis and were within safe limits. An inspection by the Environmental Health Department had been undertaken in January 2006 and the issues raised in the report had been addressed. Andrin House DS0000002150.V290563.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 X 3 3 X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 X X X 2 3 Andrin House DS0000002150.V290563.R01.S.doc Version 5.1 Page 21 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 op33 Regulation 24 (1) Requirement An annual development plan for quality assurance must be available. Previous timescales of 1.1.05, 1.8.05 and 1.11.05 not met. Now immediate. Nursing care costs must be detailed in the terms and conditions of residence. Previous timescale of 1.8.05 and 1.11.05 not met. All information required by Schedules 1 - 4 of the Care Homes Regulations 2001 must be in place in staff and service user files. Previous timescales of 1.8.05 and 01.11.05 not met. Arrangements for recording, handling, safe keeping, safe administration and disposal of medicines must be made. Previous timescale of 01.11.05 not met. The premises must be kept in a good state of repair externally and internally. Timescale of 01/11/05 not met Staff files must contain the information and documents specified in Schedule 2 DS0000002150.V290563.R01.S.doc Timescale for action 27/04/06 2. op2 5A (2) 01/06/06 3. op37 17, Schedules 1-4 01/06/06 4. op9 13 (2) 01/06/06 5. op19 23 (2) (b) 01/08/06 6. op29 19 (1) & Schedule 2 27/04/06 Andrin House Version 5.1 Page 22 7. OP7 15 (2) (b) Previous timescale of 01.11.05 not met. Now immediate. After consultation with the resident, the registered person must make the resident’s plan available to the resident. 01/07/06 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. 3. 4. 5. 6. 7. 8. Refer to Standard op33 op9 op11 op19 op29 op33 op33 op36 Good Practice Recommendations The review of policies and procedures should indicate the outcome and any action required. This recommendation was not assessed on this occasion. Handwritten MAR charts should be signed and dated by two people. Staff training in terminal and palliative care should be arranged. Dining tables and the table in the smoking room should be upgraded. All staff files should contain evidence of a Criminal Record Bureau check, proof of qualification (where applicable) and two written references. The views of residents, relatives and visitors should be sought and their views acted on. Management systems, including monitoring of care, should be in place to ensure quality of care. Staff supervision should take place every two months and include career development needs, and philosophy of care in the home. This recommendation was not assessed on this occasion. A falls risk assessment should be included as part of the admission assessment. There should always be a care plan to demonstrate how falls will be prevented where a resident is recorded as having falls. A wider range of activities to suit individual preferences should be considered. The use of fresh fruit and vegetables should be reconsidered. DS0000002150.V290563.R01.S.doc Version 5.1 Page 23 9. 10. 11. 12. OP3 OP7 OP12 OP15 Andrin House 13. 14. 15. 16. OP26 OP27 OP30 OP38 A sluicing disinfector should be provided. Additional staff cover should be considered when the induction of new staff is being carried out. Staff should receive training in dealing with difficult or challenging behaviour. Staff should undertake training in infection control. Andrin House DS0000002150.V290563.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Derbyshire Area Office 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. 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